Home Health LUPA Manipulation: Unnecessary Visits at the Payment Threshold

Home health LUPA fraud involves knowingly billing unnecessary home visits to avoid Medicare’s low-utilization payment adjustment and obtain a higher payment. A scheduler or clinician may see the pressure before billing ever sees the claim: the patient has received the care they need, but someone wants another visit to reach the payment threshold. That extra visit has a clinical story and a financial one. We connect them.

How LUPA Changes the Medicare Payment

A low-utilization payment adjustment pays the agency per visit when its visit count falls below the applicable threshold. Under the Patient-Driven Groupings Model, Medicare uses a 30-day payment period. At or above the threshold, the case-mix-adjusted period payment applies instead.

The Centers for Medicare & Medicaid Services explanation of PDGM describes 432 payment groups. The group reflects admission source, the period’s timing, the clinical group, functional impairment and comorbidities. The original PDGM thresholds ranged from two to six visits. Each group has its own LUPA threshold, and the applicable year’s group file governs. A visit count has to be read beside that group and year to explain the payment.

For a scheduler, the practical distinction is between the visits the patient needs and the count that changes how the agency gets paid. An instruction to reach the threshold makes the reason for the added visit central. The order, the clinical assessment and the visit note should explain what skilled service the patient needed.

PDGM began on January 1, 2020. It replaced the earlier payment system’s therapy-volume thresholds with grouping based on patient characteristics. LUPA still makes the number of visits consequential, through the choice between per-visit and period payment.

The Historical Five-Visit Incentive

Under the earlier system, Medicare paid per visit when a 60-day episode contained four or fewer visits. A fifth visit generally triggered a substantially higher episode payment. The HHS Office of Inspector General’s audit of claims just above the threshold explains why that jump gave agencies an incentive to bill extra visits improperly.

One more visit. A different payment.

That is the historical five-visit incentive behind the Doctor’s Choice allegations discussed below. For a current claim, the relevant threshold comes from its PDGM group and payment year.

Therapy Bonuses Were a Different Lever

Historical therapy-volume manipulation increased payment by reaching therapy-specific visit targets. The Senate Finance Committee’s report on home health therapy practices examined internal communications and visit patterns under that system. It found that companies encouraged therapists to target profitable visit counts even when patient need might not justify the pattern.

A whistleblower complaint against Amedisys alleged that the visit targets changed with the reimbursement thresholds while the therapy itself stayed substantially the same:

The distinction matters. Therapy bonuses raised payment at therapy-volume targets. LUPA changes the payment method for an episode or period. Both create a reason to examine who chose the visits and why. We see the same absurdity in the alleged practice: the reimbursement target starts writing the care plan.

Home Health Unnecessary Visit to Avoid LUPA: Why the Extra Visit Pays

An unnecessary home health visit to avoid LUPA can change the payment for the entire period. Necessary care elsewhere in the period does not justify the extra visit. The question is what supported that particular service and how it affected the claim.

The plan of care identifies the disciplines involved, the patient-specific services, and their frequency and duration. Eligibility also depends on clinical support for homebound status and skilled need. Those records give a scheduler’s account its context: what was ordered, what the clinician found, and why another visit appeared on the schedule.

We examine the decision alongside the documentation. If a clinician says the patient no longer needs the proposed service, and an instruction to reach the threshold follows, the timing and the words used matter. A revised plan, a visit note and the claim can then show how that decision moved through the agency. We pin down who requested the visit, what clinical reason they gave, and what the clinician actually did.

From the Schedule to the Paid Claim

The payment trail connects the visit documentation to the claim’s service lines, the payment group and the remittance showing what Medicare paid. The CMS Claims Processing Manual describes how Medicare combines claim information with OASIS assessment data to calculate payment. The HIPPS code represents the payment group on the claim.

The schedule shows the planned visit. The clinical note describes the service delivered. The claim shows the service billed. The payment calculation shows whether the visit count crossed the applicable threshold. The remittance shows the result after payment adjustments. We follow the same patient and period through those records so the scheduling instruction stays connected to the money.

Changes after the first claim can matter too. The manual says that when an adjusted LUPA claim reaches its group’s threshold, payment changes from a per-visit basis to the group-payment basis. For an insider who saw an extra visit entered later, the original claim and its adjustment can explain when the financial consequence occurred.

This is where a scheduler’s knowledge can be especially valuable. A completed claim contains a count. The person who received the instruction may know why the count changed.

Doctor’s Choice Settled Allegations of Pressure on Clinicians

Doctor’s Choice Home Care, a Sarasota, Florida agency, agreed to pay $675,000 to resolve allegations that employees pressured clinical personnel to increase home visits for Medicare patients to avoid LUPA. The Justice Department’s November 20, 2020 announcement described unnecessary services added to prevent the lower reimbursement that would otherwise have applied.

The alleged pressure concerned skilled visits within the historical episode-payment system. The company also settled separate referral allegations. The unnecessary-visit payment resolved a different alleged practice: increasing the visit count to protect reimbursement.

Former employees brought the whistleblower cases, and the government joined them. The Justice Department said the three former employees who brought the LUPA allegations would share in that recovery.

What the Inspector General Found Near the Threshold

The HHS Office of Inspector General estimated $191.8 million in nationwide overpayments within the $1.25 billion in Medicare payments its audit covered for services provided in 2017. It examined claims with five to seven visits under the historical payment system, using an independent medical review contractor to assess medical necessity and coding.

Of 120 sampled claims, 25 failed Medicare requirements. Some improper payments affected only part of an episode. That finding matters here: the clinical and payment examination can reach particular services within a period of care.

The Inspector General also found that 20 of those noncompliant claims would have failed under the new payment methodology. Changing the payment model did not remove the underlying defects in those claims.

The Inspector General recommended that Medicare contractors analyze claims just above the applicable threshold and target them for additional review. The Centers for Medicare & Medicaid Services agreed. The review depended on the underlying clinical documentation as well as the visit count. For an insider, those are the records that connect the payment pattern to what happened with the patient.

When the Scheduling Decision Becomes a Whistleblower Case

The Doctor’s Choice resolution shows how allegations about unnecessary visits can reach a False Claims Act case. The former employees’ account concerned pressure inside the agency, connected to services billed to Medicare. Your knowledge as a healthcare insider may connect the instruction, the clinical objection and the resulting claim in the same way. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know Why the Visit Was Added

If you schedule or deliver home health care and have seen pressure to add visits for reimbursement, talk with our whistleblower experts about the instruction and the patient records behind it. We work beside you to tie the clinical decision to the paid claim and build your strongest home health LUPA whistleblower case. We bring in home health fraud whistleblower lawyers who understand Medicare payment and medical-necessity disputes, and remain your partners throughout the case.