FOCUSED PROJECTS
HOME HEALTH AGENCIES
A review of home health agency (HHA) reimbursements in Florida for calendar years 2005through 2007 revealed a marked increase in Miami-Dade County for reimbursements forprocedure code T1021, Home Health Aide Service Unassociated with Skilled Nursing Service.
Although Miami-Dade County has approximately 20 percent of the Medicaid population of thestate and approximately 33 percent of the over age 60 demographic, the county had 91 percentof total reimbursements for procedure code T1021 services. An analysis of these services byMPI prompted an investigation of HHAs in the county. The project involved MPI and theInvestigations Unit, both of the Office of the Inspector General, several offices of the Division ofMedicaid, the Centers for Medicare & Medicaid Services (CMS), and the CMS MedicaidIntegrity Group.
The project was conducted in phases. The initial phase involved the local field officeinvestigators and nurses. Five HHAs were chosen to be reviewed as test cases. Visits to theseHHAs and their patients allowed investigators and field nurses to develop policy-specific andstatute-specific tools for use in the second phase of the project.
The second phase of the project targeted HHAs for which procedure code T1021reimbursements represented 60 percent or more of their total Medicaid reimbursements. NineHHAs were selected and the HHAs, prescribing physicians and patients were all visited duringone week in January 2008 by teams comprised of representatives of all the above mentionedagencies or units. HHAs and prescribing physicians were visited by teams of two investigators,while teams that visited patients were comprised of one investigator and one nurse. Each teamvisiting providers (9 HHAs and 36 physicians) had specific questionnaires and lists ofdocumentation to be copied and sent to the local MPI office for review. Teams that visited the336 patients had questionnaires that pertained to the services the patient received as well as anurse’s assessment.The third and ongoing phase of the project entails reviewing all information gathered through theweek-long project and making recommendations and referrals through appropriate channels.
This includes follow-up and review of records of all ancillary services provided to the patientsincluding DMEs, therapies and physician visits. The project is being expanded to other HHAsprimarily offering T1021 services.
MPI has found that overall billing for procedure code T1021 services in Miami-Dade County hasdecreased by 20 percent since the project was undertaken. The following instances ofquestionable practices by HHAs, prescribing physicians, home health aides and patients werediscovered during the course of the project:
• Aides allegedly working 20 to 25 hour days
• Patient brokering by aides
• Alteration of records
• Agencies that bill T1021 service when only housekeeping has been provided
• Agencies that bill for RN services when an LPN is attending
• Agencies using staffing pools of non-Medicaid approved providers
• Payment of physicians for referrals
• Payments to patients (in the form of gifts, services or funds)
• Patients receiving services that are not medically necessary
• Physicians with financial interests in the agencies referring to those entities.
As a result of the project, MPI has recommended termination of several of the involved HHAs.
MPI has also made referrals to MFCU and, when appropriate, referred the directors of nursingto DOH. Several of the agencies have been placed on prepayment review. Appropriate actionhas been recommended concerning several of the involved prescribing physicians. It has beencalculated that this project saved the Medicaid program $5.4 million during FY 2007-08 basedon the difference in total payments to the home health providers involved for the six-monthperiods prior to and following January 2008.