Post-Acute & Home Care Audits

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Durable medical equipment, home infusion therapy, home health, and hospice claims are a well-known area of healthcare fraud and improper payment. Review of these claims is an important step in ensuring accurate payment; driving correct utilization; and stemming the propensity toward fraud, waste, and abuse.

DME and HIT audits examine medical records for a broad range of factors to ensure adherence to coverage and reimbursement policies. Among the numerous audit parameters, Performant Healthcare Solutions reviews medical records for the following types of criteria (not a complete listing):

  • Proper documentation of written order and proof of delivery as they represent the main “chain” linking a physician’s care with the equipment and supplies delivered
  • Codes to ensure that the correct Healthcare Common Procedure Coding System (HCPCS) coding is used for the equipment or supplies delivered
  • Prescribed and delivered units compared to those billed by the provider or supplier and paid for by the plan
  • Well-prescribed rules concerning when the supplier must ensure equipment being billed is still in use and there is evidence of continued need

Home health audits offer multiple opportunities for recovery, including complex/medical necessity, coding, and documentation review for coverage and reimbursement accuracy, consistent with payer-specific criteria: 

  • CMS Prospective Payment System (PPS) coverage and reimbursement methodology for dates of service prior to January 1, 2020
  • CMS Patient Driven Groupings Model (PDGM) coverage and reimbursement methodology for dates of service effective January 1, 2020
  • Per diem/per visit claims billed on professional claims

Hospice audits help with the complexities of multiple entities that may bear accountability by determining the responsibility of Medicare, Medicaid, the managed care organization, and/or the Medicare Advantage plan at each stage of the hospice benefit. Performant conducts three categories of reviews as part of its hospice audit program:

  • Managed Medicare reviews identify plan-paid claims that should have been paid by hospice benefit or by traditional Medicare, if not related to terminal illness but occurring during hospice election.
  • Managed Medicaid reviews include complex review of skilled nursing facility (SNF) claims for validity of billed services (routine home care vs. continuous care or general inpatient care) with traditional CMS review recommended for other hospice claims
  • Dual eligibility reviews comprise a combination of Managed Medicare and Managed Medicaid reviews.