Post-Acute & Home Care Audits

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Durable medical equipment, home infusion therapy, and home health 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 SolutionsSM 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