CMS Focus on Home Health and Hospice Providers for Medicare Audits

Hospice providers are now in the process of receiving PEPPER Reports to review how they compare to other hospice providers related to their risk of billing claims for improper payments. Previously, the focus has been aimed at hospitals due to their complex billing processes and high-dollar value cases from recovery audit contractors (RACs) and zone program integrity contractors (ZPICs). Now the focus has shifted to home care and hospice providers with renewed interest. 

Now with post-acute care, these RAC and ZPIC auditors are looking at hospice and home care providers that serve patients who are also receiving other Medicare services. Additionally, rapid advance payments (RAPs) made by CMS to providers have a special place in auditors hearts to investigate unreturned RAPs. Short-stay hospital claims, Durable Medical Equipment (DME) power chairs and oxygen have more rigorous prepayment review. 

Hospice providers with high level of live discharges and patients that are considered long-stay (greater than 180 days) are making auditors pay attention. These claim reviews will be well-funded and impact a hospice provider’s cash flow while under review. 

A new report that was recently published by the Office of the Inspector General (OIG) that reflects Questionable Home Health Billing Practices that includes: 

  • visits per patient

  • outlier payments per patient

  • patients served by multiple agencies

  • late episodes

  • therapy visits

  • average payment per patient

What can we expect from these ZPIC and RAC billing investigators? How will an audit review impact your home care or hospice business?

 ZPIC and RAC audit review of home care and hospice providers