Home Health Consolidated Billing: One Agency’s Payment, Another Business’s Bill

Home health consolidated billing fraud involves knowingly billing Medicare separately for care already included in the primary home health agency’s payment. A contractor can perform the therapy and still have to look to the agency for payment. For someone in billing or accounts receivable, this home health fraud question starts where the businesses meet: the supplier’s invoice, the agency’s care period, and the separate claim sent to Medicare. The care can be real while the extra request for government money is false.

Who Receives the Medicare Payment?

The primary home health agency receives Medicare’s payment for services subject to consolidated billing, including care another business provides under arrangement. The claims manual from the Centers for Medicare & Medicaid Services assigns that responsibility to the agency overseeing the plan of care. Contracting out the work leaves the agency responsible for consolidating the bill.

Covered skilled nursing, home health aide services, physical therapy, occupational therapy, speech-language pathology, medical social services, and routine and nonroutine medical supplies, including surgical dressings, belong in this arrangement. The Medicare benefit manual puts these services and supplies in the home health base payment, with specific exceptions discussed below. A supplier’s commercial invoice to the agency and a claim to Medicare therefore ask different parties to pay for the work.

Medicare records the agency whose Notice of Admission it successfully processes as the primary agency. If the patient transfers during a 30-day period, the receiving agency that establishes the new plan assumes consolidated-billing responsibility. That makes the identity of the agency on the service date part of the payment question. This is the Medicare fee-for-service payment chain; Medicare Advantage brings a health plan’s provider contract and authorization process into the transaction.

Which Service Date and Code Apply?

The service date determines which care period and code rules apply. CMS’s home health coding and billing page identifies a master list of codes subject to consolidated billing, including the dates codes entered and left the claims edits. It also connects predecessor and successor codes. A code’s treatment on an old claim can depend on when the service occurred.

Medicare checks the code and service date on covered claim lines. The service description, code, claim format and date give a billing employee a more precise comparison than the invoice total.

When Medicare Rejects a Claim or Takes the Payment Back

Claim order changes how Medicare applies consolidated-billing edits. When the agency’s period-of-care claim arrives first, Medicare can reject or deny a covered supplier claim line before payment. When the supplier’s claim arrives first, Medicare may pay it and identify it for rejection or denial after the agency’s claim arrives. Pay first. Sort it out later. Medicare’s system checks the supplier claim’s dates against the agency’s care period.

A Notice of Admission can also reach Medicare before the agency’s payment claim. In that situation, a supplier claim within the admission period can receive payment with a line-level alert that later review may lead to recovery.

After a post-payment rejection, recovery of an institutional claim happens automatically through the claims process. A professional claim follows the contractor’s ordinary overpayment identification and recovery process. We follow both businesses’ remittances and later adjustments to distinguish a rejected request, an extra payment still outstanding, and money Medicare has already taken back.

A Separate Payment Amount Can Still Belong on the Agency’s Bill

Consolidated billing determines who bills Medicare, while the payment method determines how Medicare pays for the item. The distinction matters most at the exceptions, where a separately priced item can still belong on the primary agency’s bill.

Durable medical equipment is excluded from consolidated billing and may be billed by a supplier or a home health agency. Supplies classified as durable medical equipment follow that treatment too. The supply’s medical classification determines that treatment, and Medicare applies separate controls against duplicate equipment claims. Therapy performed by a physician is also outside the home health consolidated-billing method.

Certain injectable osteoporosis drugs go the other way: Medicare pays for them outside the home health base rate, but the home health agency must bill for them. Disposable negative-pressure wound therapy has a similar distinction. The disposable device receives separate payment through the agency, and that separate amount covers the device rather than the professional services. We follow both questions together: what Medicare pays separately, and which business must submit the bill.

What Evidence Is Needed to Prove Fraud?

We assess home health billing evidence with you by connecting the service, the business entitled to bill, the payment, and what the people submitting the claim knew. The supplier agreement and invoice show the commercial arrangement. The plan of care, service record and agency claim connect the work to the home health period. The supplier’s separate claim and remittance show what it asked Medicare to pay and what happened next.

The Centers for Medicare & Medicaid Services makes suppliers responsible for determining whether a home health period exists before furnishing services subject to consolidated billing. It also describes payment arrangements between suppliers and the primary agency. Correspondence about that arrangement can explain what each business knew before billing. An instruction to keep billing separately after the conflict was identified would give that payment history a different meaning. We examine the orders, agreement and communications with the invoice to understand what the agency knew too.

Who Provided the Wound Care?

In a complaint against Intrepid, whistleblowers alleged that facility nurses had already cared for patients’ wounds before the home health nurse arrived. The complaint alleged that the bill told Medicare a different story from the care provided:

The alleged pattern is care from one business and a Medicare bill from another. In consolidated billing, we also examine the payment arrangement between those healthcare businesses. A facility’s care record, an agency’s visit note and a supplier agreement each answer a different part of who did the work and who should receive government money.

What Happened After the Extra Payment?

A case about keeping government money shows why the accounting response matters. Accurate Home Care’s civil resolution announced in March 2019 concerned allegations that it retained duplicate reimbursements and overpayments instead of returning them. The company agreed to pay $726,957 to the United States and Minnesota to settle over money it allegedly should have returned. That case concerned what happened to money already received, a question the supplier’s initial bill cannot answer.

In a consolidated-billing inquiry, the same accounting comparison follows Medicare’s payment through any denial, adjustment and recovery. An accounts-receivable employee may know who received the notice and what decision followed. We want to understand that decision: when the company knew the payment belonged back with the government, what did it do with the money?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. If you know why a business kept submitting separate claims or kept an identified overpayment, we can assess that knowledge with the billing and payment history.

When You Know Why the Separate Bill Went Out

If you work for an agency, supplier or therapy contractor and know how the same care reached separate payment requests, speak with our whistleblower experts about the billing decisions you saw. We work beside you to connect the service agreement, Medicare claims and decisions about the money to build your strongest home health whistleblower case. We stay with you through the whole journey and bring in home health fraud whistleblower lawyers who know Medicare billing cases.