The Ultimate in Care Management Software

What Do I Do If My Home Care Agency is Being Audited?

New York -- February 20, 2024

There are several reasons why a home health agency might be audited by Centers for Medicare & Medicaid Services (CMS). While an audit can be scary and nerve wrecking, and especially so if you are positive you did everything right, it is best to be calm and try to interact with the auditor with a smile and willingness to cooperate. Here are some tips to face this intense process - and prevent it in the first place. 

Two very common problem areas are medical necessity and homebound status. Often an audit will be a review of claims that home care has been recommended by a physician and can be supported by sufficient documentation. According to the regulation, the patient’s physician must certify that the patient requires at-home care. The agency must show that the criteria is met for this requirement. The physician must evaluate their plan of care consistently in order to make sure that the billed services match the plan of care. 


The consequences for not meeting the criteria can be very dire, especially for smaller agencies. If the audit reveals that there has been improper billing or that the patients do not meet the criteria for home care, then the agency has to repay overpayments, in addition to various fees and perhaps civil suit damages.


Another cause for concern is improper billing, especially for reimbursement of services. There is also the concern for inappropriate patient solicitation and improper referral practices between the physician and the agency. All of these issues fall under the same umbrella: improper or undocumented practices. 


There are a few ways to ensure that your agency does not make itself vulnerable to an unpleasant audit. The first thing is to document everything, and regularly retrain your staff to be compliant with regulations and to follow procedures to the letter. Utilize advanced tech tracking systems to monitor everything so that audit reports are readily available and up to date. In the same vein, be sure to self audit, either yourself or through a consultant, to minimize risk and catch errors as they come. 


The utilization of advanced technology is especially key here because of how outdated tech can lead to more mistakes. Previous reporting technology requires the agency to generate their own daily reports. This can be frustrating and time consuming, and the agency is more susceptible to missing non compliant coding or tracking. Software like Carecenta, by contrast, generates reports automatically and will flag noncompliance at the outset. The DOH and CMS are mainly looking for what is compliant and what is not, and so with advanced technology, you can make sure that any issues will be flagged early and easily remedied. By having automated reporting you can take steps to prevent unnecessary audits and to have the peace of mind that should you be subject to one, you will have the proper documentation. 


The key to success for passing an audit is daily compliance monitoring. In addition to that, it is important for the monitoring to be conducted by different levels of managers and supervisors. Daily compliance monitoring is crucial to keeping a baseline of compliance and making that a regular part of the day to day routine. It cannot be stressed enough that you must prevent small mistakes from escalating into major ones. Carecenta allows such monitoring of daily compliance for different levels of review easily through its technical capabilities, and will minimize the possibility of small problems from slipping through the cracks. 


It is important that self-auditing, documenting, and correct coding become a part of your routine and a priority for all staff members. This will prevent your company from getting caught by surprise and having to scramble to get the right paperwork. Also make sure your whole staff, or at least most of the team, is trained in proper documentation so that they can catch each other’s mistakes and not get overwhelmed by mountains of work. 


Keep afloat of regulations and quickly adapt your processes to be compliant with any changes. This might be time consuming and confusing, but it is key that agencies try their absolute best to comply and to train their employees as changes come up in regulation. Again, this is the best way to prevent an uncomfortable audit and to ensure that you will not be caught by surprise. 


Another concern for home health care agencies is the risk of mishandling confidential patient information. Patients are protected under HIPAA and HITECH so that protected health information cannot be shared without the patient’s written consent. It can be easy for protected health information to be revealed improperly because of home health agency’s reliance on mobile technology and remote work, so agencies must take extra precaution to ensure that does not happen. This type of violation can be revealed during a claims or billing audit, and so agencies must protect themselves that protected health information is not improperly shared 


It is imperative that companies self-audit regularly, in order to keep ahead of potential issues coming up. These errors are serious but not impossible to catch and to do so sooner than later can save future headaches. 


If you are audited, first things first: do not panic. Remember that you have prepared for this and have taken a number of steps to prepare for this moment. The audit does not signify that the company has done anything wrong or has a long history of non-compliant work. It could just be that a complaint was filed, or someone noticed something was amiss with their billing. Sometimes an audit is triggered by someone making an honest mistake and one that can be resolved without much stress. But then there are some more serious claims that the auditor will have to investigate further. 


After an audit, CMS can require any or all of the following corrective actions: education, repayment, or suspension of payment. Education means that the company will have to go through a training program to make sure that they will be compliant in the future. Repayment, as discussed above, means that they will have to repay back anything that was improperly billed. And finally, suspension of payments means that the agency will no longer receive the payment or funding. Agencies can appeal the last two determinations but repayment is a major priority for CMS because taxpayer dollars are at stake. 


Auditing can be a very difficult experience, especially if an agency is sure that they have followed everything to the best of their ability. As the saying goes, the best defense is a good offense. This means that it is important to be proactive to prevent an audit through extensive training, careful documentation, and upkeep with regulations.