The Supplemental Medical Review Contractor (SMRC), Noridian Healthcare Solutions, has initiated a new post-payment review project targeting Medicare Part A home health claims with extended durations of care. Known as Project 01-158, the review focuses specifically on episodes lasting 361 days or longer, with dates of service from January 1 through December 31, 2024, billed under Type of Bill (TOB) 032X.

This targeted review signals increased scrutiny on long-duration home health cases and reflects broader program integrity concerns tied to care patterns under the Patient-Driven Groupings Model (PDGM).

Why CMS is Targeting Extended Episodes

According to CMS and Noridian, the review is driven by potential vulnerabilities identified under the PDGM, particularly:

• Reductions in therapy utilization
• Shifts in care patterns tied to reimbursement incentives
• Questions surrounding the continued eligibility of patients receiving prolonged services

Under the PDGM, payment is based on 30-day periods and patient characteristics rather than therapy volume. While this structure was designed to better align care with patient need, CMS has indicated that extended episodes — especially those exceeding 360 days — warrant closer evaluation to ensure services remain reasonable, necessary, and compliant.

What the Review Will Focus On

The SMRC will conduct detailed medical record reviews to assess whether patients receiving extended home health services continue to meet Medicare eligibility criteria throughout the episode. This includes a comprehensive evaluation of:

• Initial certification and face-to-face encounter documentation
• Recertifications and updated plans of care for each 30-day period under review
• Outcome and Assessment Information Set (OASIS) assessments and clinical documentation supporting changes in condition
• Skilled nursing, therapy, and home health aide visit documentation
• Evidence supporting the medical necessity, frequency, and duration of services

Importantly, providers are responsible for ensuring that all supporting documentation — including records from referring or ordering physicians — is complete, accurate, and available upon request.

Implications for Home Health Providers

This review comes at a time when home health program integrity has become an increasing focus at the federal level. The emphasis on extended episodes underscores a key expectation from CMS: continued eligibility for home health services must be clearly demonstrated — not assumed—throughout the duration of care.

Providers can expect heightened scrutiny on:

• Ongoing medical necessity
• Consistency between clinical documentation and services delivered
• Timely and complete recertifications
• Alignment between patient condition and skilled service requirements

Extended episodes, in particular, must show clear justification for continued services beyond typical recovery timelines.

Compliance Priorities Moving Forward

In light of this review, providers should take proactive steps to strengthen documentation and compliance practices, including:

• Conducting internal audits of long-duration cases
• Ensuring recertifications are timely, complete, and well-supported
• Reinforcing clinical documentation that clearly articulates skilled need
• Verifying signature requirements and physician involvement
• Aligning documentation across all disciplines involved in patient care

Bottom Line

Project 01-158 reflects a broader shift toward data-driven oversight of care patterns under the PDGM, with extended home health episodes drawing particular attention. While long-term care in the home remains appropriate for many patients, providers must be prepared to clearly demonstrate ongoing eligibility and medical necessity at every stage of the episode.

As federal scrutiny continues to evolve, strong documentation, clinical consistency, and proactive compliance will be essential to navigating this review environment successfully.