‘; 

I 

: Department of Health and Human Services I 

OFFICE OF 

INSPECTOR GENERAL 

GEOGRAPHICAL VARIATION IN VISITS


PROVIDED BY HOME HEALTH AGENCIES


+ 

Q. “’? 

$ JUNE GIBBS BROWN .

$ Inspector General s

‘% 

?-++

@ 

SEPTEMBER 1995 ‘~dz~ 2 OEI-04-93-00262 
OFFICE OF INSPECTOR GENEIU4L 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services’ (HHS) 

programs as well as the health and welfare of beneficiaries sewed by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management problems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The 010’s Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efilciency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIGS Office of Investigations (01) conducts criminal, civil, and administrative


investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of


unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions,


administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud


control units which investigate and prosecute fraud and patient abuse in the Medicaid program.


OFFICE OF EVALUATION AND INSPECTIONS 

The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. 

OEI’S Atlanta Regional Office staff prepared this report under the direction of Jesse J. 

Flowers, Regional Inspector General. 

Atlanta Region Headquarters 

Paula Bowker, Project Leader Jennifer Antico, Program Specialist


Ron Kalil, Team Leader Brian Ritchie, Program halyst


Tammy Bonney, Statistician Linda Moscoe, Program Analyst


Christopher Koehler, DRIG Barbara Tedesco, Statistician


Peggy Daniel, Program Analyst

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

GEOGRAPHICAL VARIATION IN VISITS


PROVIDED BY HOME HEALTH AGENCIES


*.-’ “9 

$ JUNE GIBBS BROWN 

$

% Inspector General 

‘5 

%--
~ 

SEPTEMBER 1995 ‘%d~a > OEI-04-93-00262

EXECUTIVE SUMMARY


PURPOSE 

To assess geographical variation in average number of Medicare visits provided by home 

health agencies. 

BACKGROUND 

In a prior 1995 inspection report, we described significant variation among home health 

agencies (HHAs) in average reimbursement per beneficiary. The highest-reimbursement 

group of HHAs received, on average, five times more Medicare reimbursement per 

beneficiary than did the lowest-reimbursement group. The variation in reimbursement 

among HHAs was largely caused by variation in the average number of visits per 

beneficiary. 

This report identifies geographic locations of high-visit HHAs. The Health Care 

Financing Administration (HCFA), State survey agencies, Regional Home Health 

Intermediaries (RHHIs), Offices of Investigations and Audit Services in the Office of 

Inspector General, and law enforcement agencies will find the report useful in targeting 

resources for detection and prevention of fraud and abuse. 

We analyzed HCFA data on Medicare reimbursement for home health services in 

calendar year 1993. The HCFA data represented services provided by 6,803 HHAs to 

over 3 million beneficiaries. 

FINDINGS 

Nineteen States Had A Larger Concentration Of High-Visit HHAs Than Other States 

Home health agencies in 19 States exceeded the national average of 50.4 visits per 

beneficiary. HHAs in those States averaged 67.2 visits per beneficiary while HHAs in the 

remaining 34 States averaged 36. 

Home Health Agencies In The southeastern Region Averaged The Most Visits Per 

Beneficiary 

HHAs in Region IV (Southeastern Region) averaged 70 visits per Medicare beneficiary. 

Seven of the eight States in Region IV were among the 19 high-visit States. 

Home Health Agencies In Four southeastern States Averaged Twice As Many Visits Per 

Medicare Beneficiary As HHAs In All Other States 

HHAs in Tennessee, Alabama, Mississippi, and Georgia combined averaged 92.7 visits 

per beneficiary. All other States averaged 45.7 visits. 

i 
About 86 percent of the HHAs located in these four Southeastern States exceeded the 

national average number of visits per Medicare beneficiary compared to 34 percent for 

the rest of the nation. 

About 35 percent of the HHAs located in these States averaged 100 or more visits per 

Medicare beneficiary compared to 7 percent of the HHAs in the rest of the nation. 

Regardless Of Their Locatiorq I-IHAs Seticed By Regional Home Health Intermediaries 

Located In The Southeast Had The Highest Number Of Visits Per Medicare Beneficiary 

Home health agencies serviced by Aetna Life Insurance in Clearwater, Florida and Blue 

Cross & Blue Shield in Columbia, South Carolina averaged 72.2 and 65.1 visits per 

Medicare beneficiary, respectively. This is about twice the average of HkL% serviced by 

Independence Blue Cross in Philadelphia, Pennsylvania and Blue Cross in Woodland 

Hills, California, which had the lowest average number of visits among the nine RHHIs. 

Some of the HHAs the two Southeastern RHHIs semice are located outside of the 

Southeast, suggesting that both the location of the HHA and the identity of the servicing 

intermediary are strongly associated with variation in visits. 

FUTURE OIG STUDIES 

In a previous report, “Variation Among Home Health Agencies in Medicare Payments For 

Home Health Services, ” 0EI-04-93-O0260, we recommended that HCFA take action to 

eliminate inappropriate variation in Medicare reimbursement among HHAs. Specifically, 

we suggested that HCFA target high-visit HHA,s for further review. We believe the 

information in this report will assist HCFA in implementing that recommendation. 

We also believe that the variation in average number of visits by State and regions raises 

questions about the uniformity of oversight among State sumey agencies, HCFA regional 

offices, and Regional Home Health Intermediaries. We plan to continue our analysis of 

these and related questions under Operation Restore Trust. 

ii 
TABLE OF CONTENTS


EXECUTIVE suMMARY


INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3


High-Visit HHAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3


Southeaster nRegio n........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


Four Southeaster notate s..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


Southeaster nIntermediarie s.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7


OIGS’T’UDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8


APPENDIX 

Number OfVisits Among 6,803 HHAs In All States . . . . . . . . . . . . . . . ... . . ..A-1


. 
INTRODUCTION 

PURPOSE 

To assess geographical variation in average number of Medicare visits provided by home 

health agencies. 

BACKGROUND 

In a prior 1995 inspection reportl, we described significant variation among home health 

agencies (HHAs) in average reimbursement per beneficiary. The variation in 

reimbursement among HHAs was largely caused by variation among HHAs in the 

average number of visits per beneficiary. The highest-reimbursement group of HHAs 

received, on average, five times more Medicare reimbursement per beneficiary than did 

the lowest-reimbursement group. Other possible causes of the variation, such as 

differences in cost per visit, beneficiary characteristics (age, sex, and illness), quality of 

services, and types of semices appeared to explain little or none of the variation. 

This report identifies geographic locations of HHAs that average a high number of visits 

per Medicare beneficiary. The Health Care Financing Administration (HCFA), State 

survey agencies, Regional Home Health Intermediaries (RHHIs), Offices of 

Investigations and Audit Services in the Office of Inspector General, and law 

enforcement agencies will find the report useful in targeting resources for detection and 

prevention of fraud and abuse. 

METHODOLOGY 

Because the extreme variation in reimbursement to HHAs was strongly linked to the 

number of visits made, we used average visits per beneficiary as a proxy for average 

reimbursement and focussed this inspection on visits. 

To determine the average number of visits per beneficiary per ~ we first identified 

all HHAs in the United States that were certified to participate in the Medicare 

program. We used HCFA’S On-line Survey and Certification Reporting System 

(OSCAR) for 1993 and identified 6,803 HHAs. 

We then identified all episodes of care claimed for reimbursement by the 6,803 HHAs 

for Medicare beneficiaries. We used HCFA’S National Claims History data file and 

identified 3,263,100 episodes of home health care in 1993. We considered each episode 

of home health care to be equivalent to one beneficiary served. An episode is a period 

of care with no breaks between visits greater than 60 days. 

1


Vhriation Among Home Health Agencies In Medicare Payments For Home Health Services - 0E144-93-I.W260 

1 
-- --

We then calculated the average number of visits per beneficiary for each of the 6,803 

HI%%. That is, we divided the total number of home health visits that an HHA made by 

the number of Medicare beneficiaries served. 

Finally, we arrayed all 6,803 HHAs by average number of visits per beneficiary. Next, we 

determined the geographic location of each of the 6,803 HHAs and classified them by 

(1) State, (2) the 10 standard Federal Regions, and (3) the 9 servicing Regional Home 

Health Intermediaries (RHHIs). RHHIs are responsible for processing Medicare claims 

from HHAs. For the purpose of our analyses, we considered Puerto Rico, Virgin Islands, 

and District of Columbia as States. 

.- .-

We conducted our inspection in accordance with the Quality Standards for Jnspech’ons 

issued by the President’s Council on Integrity and Efficiency. 

2

FINDINGS


NINETEEN STATES HAD A LARGER CONCENTRA TION OF HIGH-VISIT HEW 

THAN OTHER STATES 

@ average, home health agencies in 19 States exceeded the national average of 50.4 

visits per beneficiary. Figure 1 shows that HHAs in the 19 States averaged 67.2 visits per 

beneficiary while HHAs in the remaining 34 States averaged 36. 

Nationally, the average number of home health care visits per Medicare beneficiary in 

the 53 States ranged from a low of 20.5 to a high of 94.9. The number of visits per 

beneficiary by HHAs in the 19 high States ranged from 50.8 to 94.9. 

Appendix A shows how HHAs in each State compared to the national average of 50.4 

visits per beneficiary. 

FIGURE 1 

AVERAGE VISITS PER BENEFICIARY BY HHAs IN 19 HIGH-VISIT STATES 

COMPARED TO VISITS BY HHAs IN ALL OTHER STATES 

Avg # Of Visits Per beneficiary 

67 

/ 

36 

19 34 

Number of States 

3

.

HOME HEALTH AGENCIES IN THE SOUTHEAS TERN REGION AVERAGED 

THE MOST VISITS PER BENEFICIARY 

HHAs in Region IV (Southeastern Region) averaged 70 visits per Medicare beneficiary. 

Table 1 shows that three of the ten Federal regions exceeded the national average of 

50.4 visits per Medicare beneficiary by HHAs. The three regions were Region IV, VI, 

and I. HHAs in these three regions averaged 66.9 visits per Medicare beneficiary while 

HHAs in the remaining seven regions averaged 37.8 visits. 

TABLE 1 

;:. ,$2@lI!@U@N “l@%~Gl? NUk@@:’OF. HOMIWIEAL’&W3~” 

..’:.Y:..: ,. .. ....:’.:,.,:‘“:P~~TC~.”B-~Y~~;~GION .:, “::::” :.: , ;’: .,:.:..:: :...:.,, ,.,:.;.....,,.:...,,,.:,. r 

REGION STATES IN REGION	 AVG # OF 

VISITS* 

II*Average number of visits based on location of providers rather than beneficiaries 

Seven of the eight States in Region IV were among the 19 high-visit States for home 

health services. Home health agencies in the seven States averaged 72.3 visits per 

Medicare beneficiary in 1993. This was about 1.4 times the national average of 50.4 

home health visits per beneficiary. 

4

HOME HEALTH AGENCIES IN FOUR SO~ STATES AVERAGED 

TWICE AS MANY VISITS PER MEDICARE BENEFICIARY AS HHAs IN ALL 

OTHER STATES 

The four States were Tennessee, Alabama, Mississippi, and Georgia. Combined, HHAs 

in the four Southeastern States averaged 92.7 visits per beneficiary, All other States 

averaged 45.7 (See Figure 2.) The average number of home health visits by HHAs in 

the four Southeastern States ranged from 88.4 to 94.9 during 1993. Appendix A shows 

the average number of visits per beneficiary in each State. 

FIGURE 2 

AVERAGE VISITS PER BENEFICIARY BY HHAs IN FOUR HIGHEST-VISIT 

STATES COMPARED TO VISITS BY HHAs IN ALL OTHER STATES 

lf Visits Per Beneficiary 

94.7 

88.4 

45.7 

— 

TN AL MS GA All Others 

STATES 

J 
Most Of The HHAs Located In The Four Southeastern States Exceeded The National 

Average Number Of Visits Per Medicare Beneficiary. 

Of the 541 HHAs located in the four high-visit Southeastern States, 86 percent (465) 

averaged more than 50.4 visits per beneficiary in 1993. Conversely, about 34 percent 

(2,110) of the 6,262 HHAs located in the rest of the nation exceeded 50.4 visits per 

beneficiary. 

Table 2 shows the percentage of HHAs in each of the four States that exceeded the 

national average number of visits per beneficiary. On average, between 81 and 93 

percent of the 541 HHAs exceeded the national average. Appendix A contains a 

complete list of States showing the percentage of HHAs within those States that 

averaged above and below the national average of 50.4 visits per Medicare beneficiary. 

TABLE 2 

: P~@~b~’@fi!~@O@NA~ON~ @@ti~E ‘OF 

5~,H@41wE@m$&z13 Pm’”MEDI@.I@BqqEFqcIARY: , I 

Mississippi 93.2% 

Georgia 86.6% 

IITennessee I 86.4% II 

Alabama 81.6% 

Rest of Nation 33.7% 

About 35 Percent Of The HHAs Located In The Four southeastern States Averaged 100 

Or More Visits Per Medicare Beneficiary. 

Of the 541 HHAs located in the four highest-visit States, 188 (about 35 percent)


averaged 100 or more visits per Medicare beneficiary. Only 7.1 percent (442 of 6,262) of


HHAs in the rest of the nation averaged 100 or more visits (See Table 3).


TABLE 3 

IITennessee I 42.5% II 

IIGeorgia I 31.7% I 

IIMississippi 30.1% 

I 

IIAlabama I 27.2% II 

Rest of Nation 7.1% 

6

REGARDLESS OF WHERE THE HHA IS LOCATED, HHAs SERVICED BY 

REGIONAL HOME HEALTH INTHWEDIARIES LOCATED IN THE 

SOUTHEAST HAD THE HIGHEST NUMBER OF VISITS 

Home health agencies serviced by Aetna Life Insurance in Clearwater, Florida and Blue 

Cross & Blue Shield in Columbia, South Carolina (See Table 4) averaged about twice as 

many visits per beneficiary as HHAs serviced by Independence Blue Cross in 

Philadelphia, Pennsylvania and Blue Cross in Woodland Hills, California, even though 

some of the HHAs they service are located outside of the Southeast. This suggests that 

~ the location of the HI-IA and the identity of the servicing intermediary are strongly 

associated with variation in visits. 

RHHI	 AVERAGE # OF HOME 

HEALTH VISITS PER 

MEDICARE 

Aetna Life Insurance Co.


Clearwater, FL


Blue Cross & Blue Shield of


South Carolina


Columbia, SC


New Mexico Blue Cross and


Blue Shield, Inc.


Albuquerque, NM


Assoc Hospital Semite of Maine


South Portland, ME 

IASD Health Services Corp. 

Des Moines, IA 

Health Care Service Corp. 

Chicago, IL 

Blue Cross and Blue Shield 

United of Wisconsin 

Milwaukee, WI 

Blue Cross of California 

Woodland Hills, CA 

Independence Blue Cross 

Philadelphia, PA 

BENEFICIARY 

72.2 

65.1 

61.8 

59.9 

49.9 

42.9 

36.9 

34.2 

32.5 

7

--

The vast majority of HHAs serviced by Aetna in Clearwater, Florida and Blue Cross/Blue


Shield of South Carolina are located in the Southeastern Region. About 91 percent of


HHAs serviced by Aetna Cleanvater are in Region IV, and the remaining 9 percent are


in other geographic regions. About 89 percent of HHAs serviced by South Carolina Blue


Cross/Blue Shield are in Region IV, and about 11 percent are located in other


geographic regions.


The average number of visits per beneficia~ by HHAs serviced by Aetna Clearwater and


Blue Cross/Blue Shield of South Carolina averaged more than that for most other


RHHIs regardless of HHA location. To illustrate, the HHAs located in the Southeast


and serviced by Aetna Clearwater averaged 72.1 visits per beneficiary. Comparably, the


HHAs located outside the Southeastern Region and seticed by Aetna ClearWater


averaged 74.6 visits per beneficiary.


Likewise, the HHAs in the Southeastern Region that were serviced by South Carolina 

Blue Cross/Blue Shield averaged 66.8 visits per beneficiary. The HHAs located outside 

the Southeast and serviced by South Carolina Blue Cross/Blue Shield average 53.2 visits 

per beneficiary. While the average of 53,2 visits per beneficiary is less than that for 

HHAs sexviced by South Carolina Blue Cross/Blue Shield in the Southeast, it is higher 

than that for five of the nine RHHIs nationally (See Table 4). 

FUTURE OIG STUDIES 

In a previous report, “Variation Among Home Health Agencies in Medicare Payments For 

Home Health Services,” 0EI-04-93-O0260, we recommended that HCFA take action to 

eliminate inappropriate variation in Medicare reimbursement among HHAs. Specifically, 

we suggested that HCFA target high-visit HHAs for further review. We believe the 

information in this report will assist HCFA in implementing that recommendation. 

We also believe that the variation in average number of visits by State and regions raises 

questions about the uniformity of oversight among State survey agencies, HCFA regional 

offices, and Regional Home Health Intermediaries. We plan to continue our analysis of 

these and related questions under Operation Restore Trust. 

8

APPENDIX A


States are listed in ascending order based on average 

number of home health visits per Medicare beneficiary. 

STATE


Virgin Islands


Minnesota


Wisconsin


South Dakota


Puerto Rico


Iowa


Dist of Columbia


Alaska


Maryland


New Jersey


Oregon


Washington


Nebraska


Hawaii


Pennsylvania


Michigan


New Mexico


California


Colorado


Montana


North Dakota


# OF AVG # OF %OFHHAS 

VISITS ABOVE THE 

PER BENE NATIONAL 

AVERAGE 

OF 50 VISITS 

PER BENE 

i 

2 o% 

196 13.8% 

165 21.8% 

29 6.9% 

44 

162 17.9% 

12 o% 

12 16.7% 

71 8.5% 

53 3.8% 

71 14.1% 

55 14.5% 

52 15.4% 

20 

276 

157 

63 23.8% 

460 15.9% 

% OF HHAs 

AVERAGING 

100 OR 

MORE 

VISITS PER 

BENE 

o% 

3.1% 

3.070 

o% 

2.3% 

5.6% 

o% 

8.3% 

o% 

o% 

o% 

1.8$Z0 

3.8% 

5.0% 

1.4% 

1.9% 

4.8% 

2.4% 

120 32.59Z0 9.2% 

43 16.3940 070 

31 25.8?Z0 6.5% 

A-1

States are listed in ascending order based on average 

number of home health visits per Medicare beneficiary 

# OF AVG # OF %OFHHAs % OF HHAs 

STATE VISITS ABOVE THE AVERAGING 

PER BENE NATIONAL 100 OR 

AVERAGE MORE 

OF 50 VISITS VISITS PER 

PER BENE BENE 

A-2

States are listed in ascending order based on average 

number of home health visits ~er Medicare beneficial 

STATE


Indiana


Nevada


Texas


Massachusetts


Oklahoma


Utah


I.muisiana


Georgia


Missksimi 

Alabama 

Tennessee 

%OFHHAS 

ABOVE THE 

NATIONAL 

AVERAGE 

OF 50 VISITS 

PER BENE 

47.6% 

56.5% 

52.8% 

72.7% 

52.3% 

71.4% 

70.4% 

86.6% 

93.2% 

81.6% 

86.4% 

. 

% OF HHAs 

AVERAGING 

100 OR 

MORE 

VISITS PER 

BENE 

10.0% 

4.3$Z0 

13.0% 

16.8% 

20.3% 

16.3% 

28.6% 

31.770 

30.1% 

27.2% 

42.5V0 

I 170 

I 23 

I 143 

I 49 

I 398 

I 82 

I 73 

] 158 

I 228 

A-3