HCFA said it intends to expand the use of survey staff to combat fraud after pilot projects in Texas and New York found that Medicare was improperly billed in nearly 40% of all home health cases reviewed.
Of the cases where Medicare surveyors found a problem, 30% were because medically unnecessary supplies were claimed and 70% were because the beneficiary wasn't homebound.
During the pilot program in Texas, which ran from April 1995 through September 1995, nearly 750 beneficiary cases at 74 home health agencies were reviewed. Surveyors who regularly visit the home health agencies as part of the normal survey and certification process also were trained to look for instances of inappropriate billing. Nearly $800,000 was recovered, according to HCFA.
The new pilot program ran in conjunction with an ongoing fraud initiative called Operation Restore Trust, which is running in California, Florida, Illinois, New York and Texas.
Operation Restore Trust focuses on nursing homes, home health agencies and home medical equipment suppliers.
Last week, HHS Inspector General June Gibbs Brown announced that in the first year of the program more than $42 million in improper Medicare payments, penalties and fines had been recovered.
There have been 35 criminal convictions and 18 civil judgments obtained against providers and suppliers during the first year of Operation Restore Trust. In addition, 93 individuals and corporations have been excluded from contracting with federal programs.
"We're not talking about borderline medical decisions here," Brown said. "We're talking about things that are totally inappropriate."
One example cited involved a woman who was invited to a get-acquainted coffee at a nursing home. Later, her son found that she, and all the other residents in attendance at the coffee, had been charged for group therapy.
The Clinton administration is seeking to expand both the survey and certification initiative and Operation Restore Trust to all 50 states, according to Brown. In its fiscal 1997 budget, the White House called for the establishment of a revolving fund that would finance the program expansion with recoveries. A similar plan has been proposed by GOP leaders.
The White House estimates that $3.5 billion could be saved over a six-year period if the anti-fraud programs were taken nationwide.