Problems with Medicare's review of home health benefits have been making news for several years now. Recently, the Government Accounting Office (GAO) Reported that, despite the need for increased scrutiny of home health expenditures, Medicare's review of these decreased in the 1990s. In a test of 80 high-dollar claims that had been processed without review, GAO's auditor denied more than $135,000 in charges, or about 43 percent of the total charges for 46 of claims. A prior federal investigation estimated that in the month of February 1993 alone, Medicare paid $16.6 million for home health claims in Florida that should have been disallowed. Medicare: Need to Hold Home Health Agencies More Accountable for Inappropriate Billings (Letter Report, 06/13/97, GAO/HEHS-97-108); see also Medicare Home Health Agencies: Certification Process Is Ineffective in Excluding Problem Agencies (T-HEHS-97-180, July 28, 1997).

• 42 USC Sec. 255. Home health services
• 42 USC Sec. 1395i-3. Requirements for, and assuring quality of care in, skilled nursing facilities
• 42 USC Sec. 1395yy. Payment to skilled nursing facilities for routine service costs
• 42 USC Sec. 1396l. Hospital providers of nursing facility services
• 42 USC Sec. 1396r. Requirements for nursing facilities
• 42 USC Sec. 1396r-3. Correction and reduction plans for intermediate care facilities for mentally retarded
• 42 USC Sec. 1396t. Home and community care for functionally disabled elderly individuals
• 42 USC Sec. 1396u. Community supported living arrangements services

• Medicare Program; Schedule of Limits on Home Health Agency Costs Per Visit for Cost Reporting Periods Beginning on or After July 1, 1997; Notice, [Federal Register: July 1, 1997 (Volume 62, Number 126)] [Notices] [Page 35607-35634].
• Medicare and Medicaid Programs; Conditions of Participation for Home Health Agencies, [Federal Register: March 10, 1997 (Volume 62, Number 46)] [Proposed Rules] [Page 11005-11035]. This proposed rule revises the existing conditions of participation that home health agencies must meet to participate in the Medicare program.
• Medicare and Medicaid Programs: Use of the OASIS as Part of the Conditions of Participation for Home Health Agencies, [Federal Register: March 10, 1997 (Volume 62, Number 46)] [Proposed Rules] [Page 11035-11064]. Specifically, this proposed rule would require that HHAs use a standard core assessment data set, the ``Outcomes and Assessment Information Set'' (OASIS), when evaluating adult, non-maternity patients.
• Medicare and Medicaid Programs; Revision of Conditions of Participation for Home Health Agencies and Use of Outcome Assessment Information Set (OASIS); Proposed Rules, [Federal Register: March 10, 1997 (Volume 62, Number 46)] [Proposed Rules] [Page 11003-11005]. We are publishing two notices of proposed rulemaking relating to revised conditions of participation that home health agencies must meet to participate in the Medicare and Medicaid programs. This introduction explains the background for the two proposed rules and the interrelationship of the two documents.
• Medicare Program; Electronic Cost Reporting for Skilled Nursing Facilities and Home Health Agencies, [Federal Register: January 2, 1997 (Volume 62, Number 1)] [Rules and Regulations] [Page 26-31].
• Publication of OIG Special Fraud Alert: Fraud and Abuse in the Provision of Services in Nursing Facilities, 61FR30623 (June 17, 1996)
• Publication of OIG Special Fraud Alerts: Home Health Fraud, and Fraud and Abuse in the Provision of Medical Supplies to Nursing Facilities, 60FR40847 (August 10, 1995)
• Publication of OIG Special Fraud Alerts, FR Doc. 94-31157 (December 19, 1994)

• 42 CFR PART 409 - HOSPITAL INSURANCE BENEFITS SUBPART A - HOSPITAL INSURANCE BENEFITS: GENERAL PROVISIONS
  • 42 CFR Sec. 409.33 Examples of skilled nursing and rehabilitation
  • 42 CFR Sec. 409.40 Included services.
  • 42 CFR Sec. 409.42 Requirements and conditions for home health services.
  • 42 CFR Sec. 409.60 Benefit periods.
  • 42 CFR Sec. 409.61 General limitations on amount of benefits.
  • 42 CFR Sec. 409.87 Blood deductible.
  • 42 CFR Sec. 409.102 Amounts of payment.
• 42 CFR PART 418 - HOSPICE CARE SUBPART A - GENERAL PROVISIONS AND DEFINITIONS Selected provisions follow.
  • 42 CFR Sec. 418.2 Scope of part.
  • 42 CFR Sec. 418.3 Definitions.
  • 42 CFR Sec. 418.56 Condition of participation - Professional management.
  • 42 CFR Sec. 418.202 Covered services.
  • 42 CFR Sec. 418.304 Payment for physician services.
• 42 CFR PART 440 - SERVICES: GENERAL PROVISIONS SUBPART A - DEFINITIONS
  • 42 CFR Sec. 440.20 Outpatient hospital services and rural health clinic
  • 42 CFR Sec. 440.40 Skilled nursing facility services for individuals age
  • 42 CFR Sec. 440.70 Home health services.
  • 42 CFR Sec. 440.150 Intermediate care facility services
  • 42 CFR Sec. 440.200 Basis, purpose, and scope.
• 42 CFR PART 442 - STANDARDS FOR PAYMENT FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITY SERVICES Selected provisions follow.
  • 42 CFR Sec. 442.12 Provider agreement: General requirements.
  • 42 CFR Sec. 442.113 Correction plans for ICFs/MR: Life Safety Code and
  • 42 CFR Sec. 442.114 Correction and reduction plans for ICFs/MR: General
  • 42 CFR Sec. 442.116 Reduction plans for ICFs/MR: Specific requirements.

• Long-Term Care Bills (105th Congress)
• Nursing Home Bills (105th Congress)
• 1997 Congressional Record: Nursing Home
• 1997 Congressional Record: Hospice
• 1997 Congressional Record: Long-Term Care
• 1997 Congressional Record: Home Health
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• Medicare Home Health Benefit: Congressional and HCFA Actions Begin to Address Chronic Oversight Weaknesses. T-HEHS-98-117. 12 pp. March 19, 1998. This testimony summarizes (1) the general nature of beneficiary eligibility criteria, which opportunists exploit to provide excessive services; (2) diminished Medicare contractor review and audit effort, which makes it less likely that abusers will be caught; (3) weaknesses in Medicare's home health provider certification process; and (4) new tools that Congress has provided to strengthen oversight of the home health benefit.
• Medicare: Improper Activities by Mid-Delta Home Health. T-OSI-98-6. 9 pp. plus 1 appendix (1 pp.) March 19, 1998. GAO discusses the results of its investigation into allegations of improper Medicare billings by Mid-Delta Home Health.
• Long Term Care: Baby Boom Generation Presents Financing Challenges. T-HEHS-98-107. 14 pp. March 9, 1998. Discusses the challenges the country will face in financing long-term care for the baby boom generation, focusing on: (1) the current spending for long-term care for the elderly; (2) the increased demand that the baby boom generation will likely create for long-term care; (3) recent shifts in Medicaid and Medicare financing of long-term care; and (4) the potential role of private long-term care insurance in help finance this care.
• Medicare Home Health Agencies: Certification Process Ineffective in Excluding Problem Agencies. HEHS-98-29. 31 pp. plus 3 appendices (17 pp.) December 16, 1997. Reviews how the Health Care Financing Administration (HCFA): (1) controls the entry of home health agencies (HHA) into the Medicare program; (2) ensures that certified HHAs continue to comply with Medicare's conditions of participation and associated standards; and (3) decertifies HHAs that are not complying with Medicare's requirements.
• Medicare: Home Oxygen Program Warrants Continued HCFA Attention. HEHS-98-17. 17 pp. plus 1 appendix (7 pp.) November 7, 1997. Reviews the appropriateness of Medicare's reimbursement rates for home oxygen.
• Medicare Home Health: Differences in Service Use by HMO and Fee-for-Service Providers. HEHS-98-8. 26 pp. plus 1 appendix (2 pp.) October 21, 1997. Information on home health services provided by Medicare health maintenance organizations (HMO), focusing on: (1) how Medicare HMOs provide and manage home health services, as compared to fee-for-service providers; and (2) what is known about the appropriateness of home health services provided to HMO enrollees, especially to vulnerable populations.
• Medicare Home Health: Success of Balanced Budget Act Cost Controls Depends on Effective and Timely Implementation. T-HEHS-98-41. 12 pp. plus 1 appendix (1 pp.) October 29, 1997. Examines how the Balanced Budget Act of 1997 has addressed rapid cost growth in Medicare's home health benefit.
• Medicare: Need to Hold Home Health Agencies More Accountable for Inappropriate Billings (Letter Report, 06/13/97, GAO/HEHS-97-108). Pursuant to a congressional request, GAO reviewed Medicare's ability to detect and prevent inappropriate payments to home health agencies.
• Long-Term Care: Consumer Protection and Quality-of-Care Issues in Assisted Living (Letter Report, 05/15/97, GAO/HEHS-97-93). Pursuant to congressional request, GAO reviewed assisted living facilities (ALF), focusing on: (1) responsibilities of federal and state governments and ALFs in ensuring quality and protecting consumers living in ALFs; and (2) issues that may require further research.
• Medicare and Medicaid: Meeting Needs of Dual Eligibles Raises Difficult Cost and Care Issues (Testimony, 04/29/97, GAO/T-HEHS-97-119). Pursuant to a congressional request, GAO discussed several issues that arise in financing health care for people known as dual eligibles, Medicare beneficiaries who are also eligible for some form of Medicaid support.
• Nursing Homes: Too Early to Assess New Efforts to Control Fraud and Abuse (Testimony, 04/16/97, GAO/T-HEHS-97-114). GAO discussed the challenges that exist in combatting fraud and abuse in the nursing facility environment.
• Medicare: Home Health Cost Growth and Administration's Proposal for Prospective Payment (Testimony, 03/05/97, GAO/T-HEHS-97-92). GAO discussed Medicare's home health care benefit and the administration's forthcoming legislative proposals related to this Medicare benefit.
• Medicare Post-Acute Care: Home Health and Skilled Nursing Facility Cost Growth and Proposals for Prospective Payment (Testimony, 03/04/97, GAO/T-HEHS-97-90). GAO discussed Medicare's skilled nursing facility (SNF) and home health care benefits and the administration's forthcoming legislative proposals related to them.
• Health Care Services: How Continuing Care Retirement Communities Manage Services for the Elderly (Letter Report, 01/23/97, GAO/HEHS-97-36). Pursuant to a congressional request, GAO reviewed the processes of managed care in continuing care retirement communities (CCRC), focusing on: (1) CCRC practices for promoting wellness; (2) practices for managing care for elderly people with chronic conditions; and (3) evidence regarding the possible effect of these practices on health status and costs.
• Skilled Nursing Facilities: Approval Process for Certain Services May Result in Higher Medicare Costs (Chapter Report, 12/20/96, GAO/HEHS-97-18). Pursuant to a congressional request, GAO reviewed: (1) the growth of skilled nursing facility (SNF) costs and SNF use in relation to hospital use.
• Long-Term Care: Some States Apply Criminal Background Checks to Home Care Workers (Letter Report, 09/27/96, GAO/PEMD-96-5). Persons needing assistance with daily activities generally prefer home- and community-based services to nursing homes, and increasing numbers of elderly and disabled persons are turning to paid home care workers for such services.
• Medicaid: Oversight of Institutions for the Mentally Retarded Should Be Strengthened (Letter Report, 09/06/96, GAO/HEHS-96-131). Pursuant to a congressional request, GAO reviewed the role of the Health Care Financing Administration (HCFA), state agencies, and the Department of Justice (DOJ) in overseeing quality of care in intermediate care facilities for the mentally retarded (ICF/MR).
• Medicare: Early Resolution of Overcharges for Therapy in Nursing Homes is Unlikely (Letter Report, 08/16/96, GAO/HEHS-96-145). Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) progress in curbing overbilling for occupational speech and physical therapy services.
• Medicaid Managed Care: Serving the Disabled Challenges State Programs (Chapter Report, 07/31/96, GAO/HEHS-96-136). Pursuant to a congressional request, GAO examined state efforts to include disabled Medicaid beneficiaries in prepaid managed care programs.
• Medicaid: Waiver Program for Developmentally Disabled Is Promising But Poses Some Risks (Letter Report, 07/22/96, GAO/HEHS-96-120). Pursuant to a congressional request, GAO reviewed states' experiences in utilizing the Medicaid waiver program to provide care for developmentally disabled adults in alternative settings.
• Medicare: Federal Efforts to Enhance Patient Quality of Care (Chapter Report, 04/10/96, GAO/HEHS-96-20). Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) efforts to enhance the quality of care for Medicare beneficiaries.
• Medicare: Home Health Utilization Expands While Program Controls Deteriorate (Letter Report, 03/27/96, GAO/HEHS-96-16). Pursuant to a congressional request, GAO examined the growth in the use of Medicare home health benefits.
• Fraud and Abuse: Providers Target Medicare Patients in Nursing Facilities (Letter Report, 01/24/96, GAO/HEHS-96-18). Pursuant to a congressional request, GAO reviewed allegations of fraud and abuse related to services and supplies provided to nursing facility patients.
• Prescription Drugs and the Elderly: Many Still Receive Potentially Harmful Drugs Despite Recent Improvements (Letter Report, 07/24/95, GAO/HEHS-95-152). Pursuant to a congressional request, GAO examined the elderly's inappropriate use of prescription drugs.
• Medicare: Allegations Against ABC Home Health Care (Letter Report, 07/19/95, GAO/OSI-95-17). In response to a congressional request, GAO investigated allegations against ABC Home Health Care, a home health agency (HHA), and its participation in the Medicare home health care program.
• Medicare: Tighter Rules Needed to Curtail Overcharges for Therapy in Nursing Homes (Letter Report, 03/30/95, GAO/HEHS-95-23). Nursing homes and rehabilitation centers are taking advantage of ambiguous payment rules and lack of guidelines to bill Medicare at inflated rates for therapy services.
• Long-Term Care: Diverse, Growing Population Includes Millions of Americans of All Ages (Letter Report, 11/07/94, GAO/HEHS-95-26). Contrary to popular perception, not all Americans needing long-term care are elderly or institutionalized. Of the 12 million Americans requiring such care, 5 million are working-age adults and about half a million are children; the vast majority--10 million--live at home or in community residential facilities.
• Long-Term Care Reform: States' Views on Key Elements of Well-Designed Programs for the Elderly (Letter Report, 09/06/94, GAO/HEHS-94-227). The state agencies agree widely on the key components of well-designed programs for the elderly.
• Long-Term Care: Other Countries Tighten Budgets While Seeking Better Access (Chapter Report, 08/30/94, GAO/HEHS-94-154). In the United States, the number of people age 65 and older will exceed 20 percent of the total population by the year 2030, up from 12.5 percent in 1990.
• Long-Term Care: Status of Quality Assurance and Measurement in Home and Community-Based Services (Letter Report, 03/31/94, GAO/PEMD-94-19). This report examines how quality is ensured and measured in home and community-based long-term care services for elderly persons with disabilities.
• Long-Term Care: Support For Elder Care Could Benefit the Government Workplace and the Elderly (Letter Report, 03/04/94, GAO/HEHS-94-64). Today, about six million older Americans living at home need help with day-to-day activities, such as eating, bathing, shopping, and house cleaning.
• Long-Term Care: Private Sector Elder Care Could Yield Multiple Benefits (Letter Report, 01/31/94, GAO/HEHS-94-60). Today, about 6 million older Americans need help living at home because of their disabilities.
• HomeCare Help This site is dedicated to helping home health personnel, management and consultants locate cyberspace information which will help them cope with the rules, regulation and standards that exist in the home care field.
• HCFA Assures Medicare Beneficiaries of Rights to Advice from Physicians
• HHS: Americans Less Likely to Use Nursing Home Care Today
• HHS: Clinton Administration Proposes New Home Health Regulations
• HCFA: Skilled Nursing Facilities
• HCFA: What to look for in a Nursing Home
• HCFA: Restraint Reduction Newsletter
• HCFA: Salary Guidelines for Therapists
• HCFA: Nursing Home
• HCFA: Hospice Benefits
• HCFA: Fraud & Home Medical Equipment

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