FWA Insights: Preventing overbilling in therapeutic home services

The risk of overbilling for therapeutic services remains a pressing concern for health plan special investigative units (SIUs) and compliance teams. Excessive or inappropriate billing not only drives up costs but can also undermine the integrity of care delivery. Identifying outlier procedure codes—like those billed at unusually high rates compared to peers—is a vital step in detecting and preventing fraud, waste, and abuse (FWA). By leveraging data analytics and targeted investigative practices, health plans can pinpoint these outliers and safeguard payment accuracy for home health claims. 

Case background and outlier code identification

A recent investigation by Cotiviti’s SIU team highlighted the challenges posed by inappropriate billing in home health. In this case, a provider was flagged for excessive billing of therapeutic activities, standing out as a top outlier among its peers for several procedure codes, including CPT codes 92507, 92523, 97530, and 97110 along with HCPCS code S9152. The provider’s billing for 97530, or therapeutic activities with direct patient contact, was notably above the average paid units per patient, raising concerns about potential overutilization. Such discrepancies often signal possible FWA and warrant deeper scrutiny.

To address these concerns, Cotiviti’s SIU undertook a comprehensive review of the provider’s 12-month billing history. By analyzing claims data and conducting peer comparisons, the team confirmed that the provider was a significant outlier for the codes in question. This data-driven approach, compiled with expert review, validated the need for further action. 

Taking action against error rates

The provider was placed on prepay review for the identified procedure codes for nine months. This step ensured that claims for these codes underwent additional scrutiny before payment, reducing the risk of improper reimbursement. During this time, approximately 3,500 claim lines were pended for further examination, with the provider exhibiting a cumulative medical review error rate of 68.2%. 

Cotiviti’s SIU exposed several errors, including: 

• Documentation that did not include a complete re-evaluation, with plan of care approved by the physician to support the service
• Insufficient documentation of specific therapy provided or the activities rendered during therapy session along with a form of measurement
• No documentation of supervision from a licensed therapist
• No documentation submitted for a particular CPT code for the date-of-service billed

In addition to the documentation errors identified, Cotiviti uncovered that the number of units billed for time-based codes indicated potential “impossible day” scenarios. By maintaining the prepay review and enforcing strict documentation requirements, Cotiviti’s SIU helped prevent further overbilling and promoted compliance with regulatory guidelines.

Prioritizing accuracy in 2026

This case demonstrates how identifying outlier procedure codes and implementing targeted investigative procedures can effectively curb overbilling and FWA.

Health plan SIUs may consider these best practices to reduce improper payments in the coming year:

• Perform diligent research for state-specific guidelines for home health and the specific services provided.
• Annotate the primary age groups billed by the provider and the number of units billed. Check if the provider is billing a significant number of units per timed code for children under 10 years old. For this age group, billing durations indicating three or more hours per child warrant further scrutiny.
• Investigate the number of units billed for time-based codes that may potentially indicate “impossible day” scenarios.

By continuing to invest in comprehensive pre and postpay data analytics driven by credentialed FWA experts, health plans can help enforce higher standards to protect resources and support high-quality patient care. Prioritizing payment accuracy in 2026 helps payers ensure compliance, reduce financial risk, and maintain the trust of members and providers.

Stay on top of key payment integrity and FWA trends on the horizon in 2026. Watch our latest Payment Integrity Pulse webinar on demand for insight into the latest trends, regulations, and innovations.