UPDATE: Full-scale investigation opened on two home health agencies
The OIG has opened full-scale investigations on two home health agencies following a review of documents and evidence collected during a preliminary review of the providers’ Medicaid reimbursement filings. The providers were identified during a fraud detection operation (FDO) conducted in the first quarter of fiscal year 2023 that used an algorithm to uncover potentially fraudulent billing practices previously observed among home health providers.
The full-scale investigation will allow the OIG to take a closer look at patterns within the providers’ billing and medical records, including additional interviews and reviews of a more extensive set of client medical records. This information will allow the OIG to understand the providers’ operations better. This step is necessary to determine if there are fraudulent or wasteful activities.
Upon enrolling in Medicaid, providers are required to maintain complete and thorough medical records that show the necessity of services and information supporting that the procedure was administered correctly. However, the preliminary review of documents from the two providers revealed that key required items were missing from clients’ medical records, including physician orders, progress notes, assessments, reassessments, and care plans. These items ensure clients receive the appropriate amount, duration and scope of Medicaid-funded services.