Home Health Agencies Rarely Furnished Services Via Telehealth Early in the COVID-19 Public Health Emergency, A-05-21-00026
- Issuer
- Office of Inspector General
- Document type
- Report
- Date
- 2023-07-01
Summary
An audit report by the Department of Health and Human Services Office of Inspector General, Report No. A-05-21-00026, dated September 2023, on home health services furnished via telehealth early in the COVID-19 public health emergency. OIG reviewed a stratified random sample of 200 home health claims with beginning service dates from March 1 through December 31, 2020, drawn from a frame of approximately 7 million claims with $12.4 billion in Medicare payments. The report finds that 4 of the 200 sampled claims had services furnished via telehealth, estimates 127,999 such claims in the frame, and finds that none of the four fully complied with Medicare requirements. It recommends that CMS monitor home health agency reporting of new G-codes, and states that CMS concurred.
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Full text
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
HOME HEALTH AGENCIES RARELY
FURNISHED SERVICES VIA TELEHEALTH
EARLY IN THE COVID-19 PUBLIC
HEALTH EMERGENCY
Inquiries about this report may be addressed to the Office of Public Affairs at
Public.Affairs@oig.hhs.gov.
Amy J. Frontz
Deputy Inspector General
for Audit Services
September 2023
A-05-21-00026
Office of Inspector General
https://oig.hhs.gov
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Notices
THIS REPORT IS AVAILABLE TO THE PUBLIC
at https://oig.hhs.gov
Section 8M of the Inspector General Act, 5 U.S.C. App., requires
that OIG post its publicly available reports on the OIG website.
OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS
The designation of financial or management practices as
questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
Report in Brief
Date: September 2023
Report No. A-05-21-00026
Why OIG Did This Audit Home Health Agencies Rarely Furnished Services Via
In response to the COVID-19 public
health emergency (PHE), the Centers Telehealth Early in the COVID-19 Public Health
for Medicare & Medicaid Services Emergency
(CMS) expanded telehealth benefits
to limit community spread and keep
What OIG Found
vulnerable patients in their homes
HHAs rarely furnished services via telehealth early in the COVID-19 PHE;
while maintaining access to care. In
however, for the few claims in our sample with services furnished via
April 2020, CMS revised Medicare
telehealth, HHAs did not fully comply with Medicare requirements for
regulations on an interim basis to
providing them. Of the 200 sampled claims, 4 claims had home health services
retroactively allow home health
furnished via telehealth, so we estimate that there are 127,999 claims in the
agencies (HHAs) to use telehealth
sampling frame with such services. None of the four claims fully complied
services beginning March 1, 2020. In
with Medicare requirements for home health services furnished via telehealth.
November 2020, CMS finalized
The errors occurred because the HHAs were unfamiliar with the Medicare
changes to those regulations to
requirements for such services, which were new early in the COVID-19 PHE.
permanently allow home health
Of the remaining 196 sampled claims, 194 claims did not have home health
services to be furnished via
services furnished via telehealth. For the remaining two sampled claims, we
telehealth. While Medicare makes
were unable to obtain medical records, so we could not determine whether
payments for some types of
home health services were furnished via telehealth.
telehealth services, the final
regulations prohibit payments for
Beginning July 1, 2023, CMS now requires HHAs to report the use of telehealth
home health services furnished via
services on home health claims. CMS has instructed HHAs to use one of two
telehealth. At the start of our audit,
G-codes to report the services on claims and to list each service as a separate,
CMS did not require HHAs to report
dated line item. CMS stated that such reporting will allow it to analyze the
telehealth services on Medicare
characteristics of patients utilizing telehealth and give it a broader
claims. Therefore, oversight agencies
understanding of the determinants that affect who benefits most from those
lacked the ability to effectively
services. Furthermore, in their March 2022 Report to the Congress, the
identify and monitor those services.
Medicare Payment Advisory Commission recommended tracking the use of
telehealth on home health claims to improve payment accuracy.
Our objective was to determine
whether home health services
furnished via telehealth early in the What OIG Recommends and CMS Comments
COVID-19 PHE were provided and We recommend that CMS monitor HHA reporting of the new G-codes to
billed in accordance with Medicare determine whether further updates to regulations or guidance are necessary.
requirements.
CMS concurred with our recommendation and provided information on the
How OIG Did This Audit actions that it has taken and plans to take to address the recommendation.
We selected a stratified random
sample of 200 home health claims
with beginning service dates from
March 1 through December 31, 2020.
We reviewed medical records to
evaluate compliance with Medicare
regulations for providing and billing
telehealth services.
The full report can be found at https://oig.hhs.gov/oas/reports/region5/52100026.asp.
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................... 1
Why We Did This Audit ....................................................................................................... 1
Objective ............................................................................................................................. 1
Background ......................................................................................................................... 1
The Medicare Program and Payments for Home Health Services ......................... 1
Medicare Coverage for Home Health Services ....................................................... 1
Medicare Requirements for Home Health Services Furnished via Telehealth....... 2
How We Conducted This Audit ........................................................................................... 2
FINDINGS ......................................................................................................................................... 3
New Guidance on Documenting Telehealth Services on Home Health Claims.................. 4
RECOMMENDATION ....................................................................................................................... 4
CMS COMMENTS ............................................................................................................................ 4
OTHER MATTERS ............................................................................................................................. 5
APPENDICES
A: Audit Scope and Methodology ....................................................................................... 6
B: Statistical Sampling Methodology .................................................................................. 8
C: Sample Results and Estimate ........................................................................................ 10
D: CMS Comments ............................................................................................................ 11
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026)
INTRODUCTION
WHY WE DID THIS AUDIT
In response to the COVID-19 public health emergency (PHE), the Centers for Medicare
& Medicaid Services (CMS) expanded telehealth benefits to limit community spread of the virus
and keep vulnerable patients in their homes while maintaining access to care. In April 2020,
CMS revised Medicare regulations on an interim basis to retroactively allow home health
agencies (HHAs) to use telehealth services beginning March 1, 2020. In November 2020, CMS
finalized changes to those regulations to permanently allow home health services to be
furnished via telehealth. The final regulations have new requirements regarding documenting
such services and also prohibit payments for home health services furnished via telehealth. At
the start of our audit, CMS did not require HHAs to report telehealth services on Medicare
claims. Therefore, oversight agencies lacked the ability to effectively identify and monitor
those services.
OBJECTIVE
The objective of our audit was to determine whether home health services furnished via
telehealth early in the COVID-19 PHE were provided and billed in accordance with Medicare
requirements.
BACKGROUND
The Medicare Program and Payments for Home Health Services
The Medicare program provides health insurance coverage to people aged 65 and over, people
with disabilities, and people with end-stage renal disease. CMS administers the program.
Medicare Parts A and B cover eligible home health services under a prospective payment
system (PPS). The PPS covers part-time or intermittent skilled nursing care and home health
aide visits, therapy (physical, occupational, and speech-language pathology), medical social
services, and medical supplies. Under the home health PPS, CMS pays HHAs for each 30-day
billing period of home health care that an eligible patient receives. CMS contracts with four
Medicare administrative contractors (MACs) to process and pay claims submitted by HHAs.
MACs are also responsible for conducting reviews of home health claims to ensure compliance
with Medicare requirements.
Medicare Coverage for Home Health Services
Medicare covers home health services for eligible patients who are homebound and in need of
skilled services. A physician or allowed nonphysician practitioner (NPP) must conduct a face-to-
face visit to evaluate the patient’s current condition and determine eligibility for home health
services. To initiate home health care, a physician or NPP must send the HHA a verbal or
written order for it. Within 5 days after the start of home health care, Medicare requires the
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 1
HHA to perform a comprehensive assessment that accurately reflects the patient’s current
health status and medical needs. The HHA, in conjunction with the physician or NPP, uses the
results from the comprehensive assessment and the patient’s medical history to develop the
home health plan of care. The plan of care outlines, among other things, the services to be
provided, the amount and frequency of visits, and the predicted outcomes of treatment.
Medicare Requirements for Home Health Services Furnished via Telehealth
Home health services are typically furnished by HHAs via in-person home visits, but some may
now be furnished via telehealth. In April 2020, CMS revised Medicare regulations on an interim
basis to retroactively allow HHAs to use telehealth services beginning March 1, 2020. 1 In
November 2020, CMS finalized changes to those regulations to permanently allow home health
services to be furnished via telehealth. The final regulations have new requirements regarding
documenting such services and prohibit payments for them, including: 2
• The plan of care must include any provision of telehealth services.
• The plan of care must describe how the use of telehealth services is tied to patient-
specific needs identified in the comprehensive assessment.
• Telehealth services cannot substitute for a home visit ordered as part of the plan of
care.
• Telehealth services cannot be considered a home visit for the purposes of patient
eligibility or payment.
HOW WE CONDUCTED THIS AUDIT
Our audit covered Medicare claims for home health episodes with services furnished via
telehealth and beginning service dates from March 1 through December 31, 2020. During the
audit period, CMS did not require HHAs to report telehealth services on Medicare claims.
Therefore, we could not determine from the claim data whether the home health episodes
included services furnished via telehealth. As a result, our sampling frame included Medicare
claims for home health episodes without services furnished via telehealth.
The sampling frame consisted of approximately 7 million home health claims with $12.4 billion
in Medicare payments. From this sampling frame, we selected a stratified random sample of
200 claims with payments totaling $365,419. We contacted HHAs to obtain medical records for
each of the 200 sampled claims. We reviewed the medical records we received to determine
whether home health services were furnished via telehealth and estimated the number of
1
85 Fed. Reg. 19230 (April 6, 2020) and 42 CFR § 409.43(a).
2
85 Fed. Reg. 70298 (November 4, 2020) and 42 CFR § 409.43(a)(3)(i)(B).
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 2
claims with such services in our sampling frame. We also determined whether home health
services that were furnished via telehealth complied with Medicare requirements for providing
them.
Some of the sampled claims without home health services furnished via telehealth had
language in their plans of care that provided the option to use such services. We discuss the
results of our review of such language in the Other Matters section of this report.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Appendix A contains the details of our scope and methodology, Appendix B describes our
statistical sampling methodology, and Appendix C contains our sample results and estimate.
FINDINGS
HHAs rarely furnished services via telehealth early in the COVID-19 PHE; however, for the few
claims in our sample with services furnished via telehealth, HHAs did not fully comply with
Medicare requirements for providing them. Of the 200 sampled claims, 4 claims had home
health services furnished via telehealth, so we estimate that there are 127,999 claims in the
sampling frame with such services. 3 None of the four claims fully complied with Medicare
requirements for home health services furnished via telehealth. The errors occurred because
the HHAs were unfamiliar with the Medicare requirements for such services, which were new
early in the COVID-19 PHE. Of the remaining 196 sampled claims, 194 claims did not have
home health services furnished via telehealth. For the remaining two sampled claims, we were
unable to obtain medical records, 4 so we could not determine whether home health services
were furnished via telehealth.
None of the four sampled claims with home health services furnished via telehealth fully
complied with Medicare requirements for such services. Of these four sampled claims, two did
not include a provision in the plan of care allowing for the use of telehealth services. The
remaining two claims had provisions in their plans of care allowing for the use of telehealth
services, but the plans of care did not tie the use of telehealth services to patient-specific needs
identified in the comprehensive assessment. In addition, for one of the remaining two claims,
telehealth services substituted for a home visit ordered in the plan of care. These errors did not
3
The 90-percent confidence interval for the number of claims in the sampling frame with home health services
furnished via telehealth was 16,018 to 239,980.
4
We were unable to contact the HHAs because they were no longer in business.
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 3
result in overpayments. The errors occurred because the HHAs were unfamiliar with the
Medicare requirements for such services, which were new early in the COVID-19 PHE.
New Guidance on Documenting Telehealth Services on Home Health Claims
In its 2023 Home Health PPS Final Rule, 5 CMS required HHAs to report the use of telehealth
services on home health claims beginning July 1, 2023.6 CMS has instructed HHAs to report the
services on claims as separate, dated line items and to do so using one of the following two G-
codes:
• G0320: Home health services furnished using synchronous telemedicine rendered via a
real-time, two-way audio and video telecommunications system.
• G0321: Home health services furnished using synchronous telemedicine rendered via
telephone or other real-time, interactive, audio-only telecommunications system.
CMS indicated that requiring HHAs to report those codes will help it understand HHA use of
telehealth. For example, CMS stated that such reporting will allow it to analyze the
characteristics of patients utilizing telehealth and give it a broader understanding of the
determinants that affect who benefits most from those services. Furthermore, in its March
2022 Report to the Congress, the Medicare Payment Advisory Commission (MedPAC)
recommended tracking the use of telehealth on home health claims to improve payment
accuracy. 7
RECOMMENDATION
We recommend that CMS monitor HHA reporting of the new G-codes to determine whether
further updates to regulations or guidance are necessary.
CMS COMMENTS
In written comments on our draft report, CMS concurred with our recommendation and
provided information on actions that it had taken or planned to take to address our
recommendations. CMS also provided technical comments on our draft report, which we
addressed as appropriate. CMS’s comments, excluding the technical comments, are included as
Appendix D.
5
87 Fed. Reg. 66790 (November 4, 2022).
6
In this report, we use the terms “telemedicine” and “telehealth” interchangeably.
7
MedPAC, March 2022 Report to the Congress: Medicare Payment Policy, Chapter 8: Home Health Care Services.
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 4
OTHER MATTERS
During our review of medical records for the 194 sampled claims without home health services
furnished via telehealth, we found that 60 records had plans of care that included language
allowing for such services. We reviewed that language and determined that 58 of the 60 plans
of care did not meet Medicare requirements. In all 58 plans of care, the use of telehealth
services was not tied to patient-specific needs identified in the comprehensive assessment. In
16 of the 58 plans of care, the language suggested the use of telehealth services as a substitute
for a home visit. Some plans of care had more than one type of error, and some language was
duplicated in other plans of care. We shared the following examples 8 with CMS personnel, and
they agreed that such language did not meet Medicare requirements:
• “May use telehealth and telecommunications to provide services as necessary and
appropriate according to the patient’s condition and in accordance with the plan of
care.” This language was duplicated in 12 plans of care and does not tie the use of
telehealth services to patient-specific needs identified in the comprehensive
assessment.
• “All disciplines (except home health aide) may provide telehealth phone/remote/virtual
visits in lieu of an in-person visit that does not require hands on or in-person
assessment when an in-person visit is not possible due to the public health emergency
related to the COVID-19 pandemic.” This language was duplicated in 12 plans of care
and suggested the use of telehealth services as a substitute for a home visit.
The errors in language occurred because at the time the plans of care were written, furnishing
home health services via telehealth was only recently allowed. HHAs reported dealing with
many regulatory changes from the PHE and thinking that the language met requirements.
8
We shared a total of six examples of language in error with CMS personnel, and they agreed with our
assessments. We include only the most duplicated example for each type of error.
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 5
APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our audit covered Medicare claims for home health episodes with services furnished via
telehealth and beginning service dates from March 1 through December 31, 2020. The
sampling frame consisted of approximately 7 million home health claims with $12.4 billion in
Medicare payments. From this sampling frame, we selected a stratified random sample of 200
claims with payments totaling $365,419. For each sampled claim with home health services
furnished via telehealth, we evaluated compliance with requirements in
42 CFR § 409.43(a)(3)(i)(B).
We assessed CMS’s internal controls and compliance with laws and regulations necessary to
satisfy the audit objective. Specifically, our review of internal controls focused on CMS’s
oversight of how home health services furnished via telehealth were provided and billed. We
assessed whether CMS implemented control activities through its policies and guidance. Our
internal control review may not have identified all internal control deficiencies that may have
existed at the time of this audit.
To assess the reliability of the data obtained from CMS’s National Claims History file, we
(1) performed electronic testing for obvious errors in accuracy and completeness, (2) reviewed
existing information about the data and the system that produced them, and (3) traced a
stratified random sample of 200 home health claims to source documents. We determined
that the data were sufficiently reliable for the purposes of this report.
We conducted our audit from June 2021 through June 2023.
METHODOLOGY
To accomplish our objective, we:
• reviewed Federal requirements related to home health services furnished via telehealth,
• communicated with CMS officials to gain a better understanding of its policies and
guidance concerning Federal requirements for home health services furnished via
telehealth,
• extracted Medicare home health claim data for the audit period from the National
Claims History file,
• created a sampling frame of 6,969,435 claims totaling $12,367,409,010,
• selected a stratified random sample of 200 claims for detailed review (Appendix B),
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 6
• reviewed available data from CMS’s Common Working File for the sampled claims to
determine whether the claims had been canceled or adjusted,
• obtained billing and medical record documentation from HHAs to support the sampled
claims,
• reviewed that documentation to determine whether home health services were
furnished via telehealth and whether such services complied with Medicare
requirements for providing them,
• used the results of the sample to estimate the number of claims with home health
services furnished via telehealth in our sampling frame (Appendix C), and
• discussed the results of our audit with CMS officials.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 7
APPENDIX B: STATISTICAL SAMPLING METHODOLOGY
SAMPLING FRAME
Our sampling frame consisted of 6,969,435 Medicare home health claims totaling
$12,367,409,010 and with beginning service dates from March 1 through December 31, 2020.
The sampling frame contained only final home health claims 9 that had payments greater than
$0, had Medicare as the primary payer, were not submitted by an HHA under investigation, and
had not been previously reviewed by us or CMS contractors. During the audit period, CMS did
not require HHAs to report telehealth services on Medicare claims, so we could not identify
claims for home health episodes with services furnished via telehealth. Therefore, our
sampling frame included Medicare claims for home health episodes without services furnished
via telehealth.
SAMPLE UNIT
The sample unit was a Medicare home health claim.
SAMPLE DESIGN AND SAMPLE SIZE
We used a stratified random sample containing three strata based on the number of visits billed
and outlier status. We selected 200 Medicare home health claims for review, as shown in Table 1.
Table 1: Frame Description and Sample Size
Frame Information
Sample
Stratum Number of Frame Dollar
Size
Claim Description Frame Units Value
1 5 or fewer visits 2,912,486 $3,765,751,855 75
2 6 or more visits with no outlier 3,722,510 7,677,555,743 95
3 6 or more visits with outlier 334,439 924,101,412 30
Total 6,969,435 $12,367,409,010 200
SOURCE OF RANDOM NUMBERS
We generated the random numbers using the Office of Inspector General (OIG), Office of Audit
Services (OAS), statistical software.
9
We define final home health claims as those tied to payments in full, which do not include requests for
anticipated payment. Specifically, we included only type-of-bill codes 327, 329, 32G, 32H, 32I, and 32M.
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 8
METHOD OF SELECTING SAMPLE UNITS
We sorted the items in each stratum by the Data Extract System View Receiving Link Number 10
and then consecutively numbered the items in each stratum in the sampling frame. We
generated the random numbers for our sample according to our sample design and then
selected the corresponding frame items for review.
ESTIMATION METHODOLOGY
We used the OIG/OAS statistical software to estimate the number of claims with home health
services furnished via telehealth in our sampling frame. We calculated the point estimate and
the corresponding two-sided 90-percent confidence interval for this estimate.
10
This field contains a sequentially assigned number for the claims included in the file and allows the user to tie
children line items to the parent claim.
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 9
APPENDIX C: SAMPLE RESULTS AND ESTIMATE
Table 2: Sample Results
Frame Sample Value of Sample Items
Stratum Size Value of Frame Size Sample With Telehealth
1 2,912,486 $3,765,751,855 75 $104,515 2
2 3,722,510 7,677,555,743 95 186,792 1
3 334,439 924,101,412 30 74,112 1
Total 6,969,435 $12,367,409,010 200 $365,419 4
Table 3: Estimated Number of Claims With Home Health Services
Furnished via Telehealth in the Sampling Frame
(Limits Calculated at the 90-Percent Confidence Level)
Point estimate 127,999
Lower limit 16,018
Upper limit 239,980
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 10
APPENDIX D: CMS COMMENTS
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 11
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 12
Medicare Home Health Services Furnished via Telehealth (A-05-21-00026) 13
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