Incorrectly Billed Visit Units That Trigger Outlier Payments on Home Health Claims

Medicare requires providers to bill claims accurately to be paid correctly and promptly by Medicare Administrative Contractors (MACs). During previous home health agency compliance work, we observed claims where providers incorrectly billed single-discipline visit units (greater than 8 hours) that resulted in overpayments equal to the outlier payment. MACs pay outlier payments on home health claims for enrollees who incur unusually large costs that are determined by the visit units billed on the claim. Nationwide home health claims data for the most recent 30-month period shows that the average duration of a home health visit is 45 minutes. Our audit will cover Medicare outlier payments for home health visits for single disciplines that were billed in excess of 4 hours. Our objective is to determine whether selected home health claims with outlier payments complied with certain Medicare billing requirements.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
November 2025	CMS	Incorrectly Billed Visit Units That Trigger Outlier Payments on Home Health Claims	Office of Audit Services	OAS-26-05-001	2027