CMS/MACs Need to Reduce Improper Billing of Home Health

Members | April 20, 2017 | by Peter Notarstefano

A  March 2017 Government Accountability Office (GAO) report states that the Centers for Medicare and Medicaid Services (CMS) needs to improve their oversight of Medicare Administrative Contractors (MACs) in order to reduce the incidence of improper billing of home health care claims.

A March 2017 Government Accountability Office (GAO) report states that the Centers for Medicare and Medicaid Services (CMS) needs to improve their oversight of Medicare Administrative Contractors (MACs) in order to reduce the incidence of improper billing of home health care claims. The GAO reported that the Medicare Fee-for-Service Program made incorrect payments of $41.1 billion in 2016 due to problems with oversight and contracts, which is an 11 percent improper payment rate. The report focused on MAC provider education procedures that were used to assure appropriate fee-for-service payments of home health from 2013 to 2016.

CMS has very limited oversight of the MACs, according to the report, and the result is billions of dollars of improper payments. The GAO concluded that the absence of information and performance measurements from CMS increased improper billing. Also, there are no negative consequences to the referring entity for improper payments, but the home health agency and DME supplier receive claim denials due to insufficient documentation.

GAO recommends that CMS should:

  • Require sufficient detail in MAC reporting to determine the extent to which MACs’ provider education department efforts focus on vulnerable areas
  • Explicitly require MACs to work together to educate referring providers on proper documentation for DME and home health services
  • Establish performance metrics for future probe and educate reviews.

The U.S. Department of Health and Human Services concurred with GAO’s recommendations. The GAO will provide updated information when it confirms what actions the agency has taken in response to the recommendations.