Integrity Advantage was tasked to complete a review of medical records for a state Medicaid agency. If you are reviewing cases involving codes S5125 (Attendant care services), S5150 (Unskilled Respite Care) or T1019 (Personal Care Services), check out our case study. It’s full of eye opening findings and issues related to Home Health Services billing practices.

A Case Study: Medicaid Home Health Services

Integrity Advantage was hired to perform several Home Health reviews for a state Medicaid agency. Data analysis for the providers indicated unusual billing as the providers appeared to round units to the nearest half-hour and bill only an even number of units. Medical records were requested for various home health care services (HHCS)to include personal care services (PCS) and respite care (RSP) services. These records were reviewed against required Medicaid guidelines to determine if services billed were supported in the documentation

Codes Involved:

Key Elements of the Review:

Electronic Visit Verification (EVV)

A technological solution used to electronically verify whether personal care providers and, later, home health providers delivered or rendered services as billed.

Person-Centered Service Plans (PCSP)

The plan of care must include the identification of the responsible discipline(s) and the frequency and duration of all visits as well as those items listed in 42 CFR 484.60(a)that establish the need for such services. All care provided must be in accordance with the plan of care.

All services were denied for not meeting requirements. Read on for more.

Based on State Medicaid Guidelines, here are the issues we identified:

There are many aspects to reviewing home health claims and different states may require different documentation to support services. It's important to thoroughly research and understand the requirements for your particular state before your engage in a review to determine whether criteria are met. In addition, it is recommended that you leverage certified coders and nurses who are skilled in the review of these services.

Should you need support in identifying and reviewing allegations related to home health FWA, we can help. With more than 30 years of experience supporting payers, Integrity Advantage provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Program Integrity Teams and SIUs.

Credentials matter.

Our team not only has the expertise, but the credentials and certifications that give you confidence to choose us including AHFI, CPC, CFE, RN and more. For a full list, please visit www.integrityadvantage.com

Learn More Today!

Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. We provide FWA services to payers around the country.

If you need a program assessment, program growth strategy, investigations, medical reviews or training support -- reach out today.

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