Compliance Risks Pertinent To Home Health Agencies

May 4, 2021

How is your Home Health Agency (HHA) complying with state and federal compliance regulations and standards? This might seem like a loaded question. That’s partly because it is. In this blog, we’re going to look into some compliance risks that could happen in your day-to-day operations, and how to avoid such noncompliance.

When an agency that is supported by government reimbursements doesn’t have a Compliance Program or doesn’t adhere to the healthcare laws that have been developed around compliance, its providers and/or leaders can experience costly fines, jail time, and even being dropped from payor programs altogether, namely Medicare and Medicaid.

Transparency & Training: Written Policies and Procedures

For any HHA’s Compliance Program to succeed, a Compliance Officer must be relegated to
undertake the responsibilities of staying in the know of current and changing compliance laws, as well as developing written compliance policies and procedures, and conducting employee training. This staff person must exhibit an air of approachability for other staff members who may have questions, or who may even report compliance issues.

In addition to maintaining compliance, your agency will benefit from having a program in place by realizing cost savings, improving quality of care, and also lending cohesiveness and transparency to your HHA’s operations.

First things first though. Let’s say you’ve appointed a Compliance Officer, or even accepted the role yourself. Now, let’s face it; employees are never going to ask to be trained. Rather, it is the Compliance Officer’s job to implement such training – and meaningful training, so that a written policies and procedures compliance binder doesn’t merely sit atop a shelf collecting dust.

  • Do train employees regarding what, when, and how to report any suspected fraud abuses, even if anonymously, and include such protocols in your written plan.
  • Do email employees with updates and make certain that they know where to find your written compliance policies and procedures.
  • Do foster trust within the workplace such that employees know there is no illegal backlash if reporting.
  • Do document and reconcile any compliance issues immediately if uncovered by the
    Compliance Officer.
  • Do assess and update your Compliance Program on a regular basis, and document any changes in your written compliance plan.

What Issues or Risks Fall Into the Non-Compliance Realm for HHAs?

What is it that home health agencies need to be aware of concerning compliance risks? You might be surprised, but it’s not just payment fraud. Read on.


The government’s Health Care Fraud Prevention & Enforcement Action Team (HEAT) is comprised of law enforcement from the U.S. Department of Justice (DOJ) and professional investigators from the Department of Health and Human Services (HHS). It is their job to enforce compliance standards and regulatory laws that have been enacted due to the rise of Medicare and Medicaid fraud and abuse among home health agencies. HEAT is increasingly turning up the heat.

Medicare Claims Audits and Reviews

rivate contractors are employed to investigate and report those agencies, hospitals, and other healthcare organizations who seek provider reimbursement through government and state agencies in illegal fashions.

Inadequate Electronic Health Records (EHRs)

Take great care when selecting a vendor to help you with compliance along the lines of EHRs. Some EHR software packages are of the cookie-cutter variety and are far too general or redundant to capture individualized patient data, thus failing to meet federal regulations concerning EHRs. KanTime [hyperlink website]is a trusted vendor in the state of Texas and surrounding areas and offers a federally compliant EHR software platform.

Medicaid Coding and Billing Activity Audits

Over the past few years, home health agencies have seen an increase in Medicaid Recovery Audit Contractors (MDRACs) and Medicaid Integrity Contractors (MICs) visits. Due to healthcare reform, MDRACs are now mandatory in each state. Your Compliance Officer should be well versed in all that is relative to lawful, pertinent coding and billing activities and should train staff accordingly.


Violations of strict federal privacy laws are penalized by hefty fines and/or jail time. The majority of these violations involve outside intrusion and theft of EHRs or loss of paper records. Again, it is of the utmost importance to ensure you’ve selected the right vendor who will be able to safeguard your patient’s electronic health information. In the meantime, expect these laws to only stiffen.

Whistleblowers Reporting Medicare Overpayments

A very time-consuming and concerning situation occurs should the agency not catch an overpayment and an unhappy employee files a Qui Tams lawsuit, for which providers have only 60 days to resolve and reimburse for the discrepancy. Your Compliance Officer must not only thoroughly train billers to report to them when an overpayment is discovered but oversee the process and conduct their own internal audits on a regular (and even “unscheduled”) basis.

Special Investigative Units (SPUs)

SPUs are enlisted by third-party payors. Most of these payors attend working groups headed up by HHC or the DOJ. If you are audited by the HHC or DOJ, you can bet your next visit will be from a SPU.

Screening Employees

HHS and its Office of Inspector General (OIG) are discovering more and more agencies employing those who have committed Medicare or Medicaid fraud, patient abuse or neglect, or who have received felony convictions at past places of employment or in their private lives. OIG’s List of Excluded Individuals and Entities (LEIE) contain those who are blacklisted from working at agencies that seek government payor reimbursement. Thus, it is beyond prudent to review LEIE before hiring new employees (and existing staff, for that matter) so as to avoid monetary civil penalties.

Medicare Number Suspension

Full cooperation of any outside site audit is highly recommended, as is alerting Medicare of an agency address change. Among other reasons an agency could have their Medicare number suspended would be due to a variety of alleged violations, or if it has engaged in illegal billing practices.

The large majority of compliance risks can be averted when an HHA has a solid Compliance Program in place, along with a designated Compliance Officer. “Full-service” compliance software is also a must. Look to KanTime to provide specific software tailored for your free-standing home health agency’s adherence to compliance regulations.

For more information, you can also visit the OIG website at Likewise, check out our website for future resources on compliance.

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