Miami-area outlier payments draw scrutiny

In 2008, Miami-Dade County, Fla., was home to 2% of Medicare beneficiaries receiving home-health care, but Miami-Dade providers collected more than half of the $1 billion the government spent in outlier payments for home-health services, according to a new report from HHS' inspector general's office.

The office analyzed all home-health claims that Medicare paid in 2008 in order to find aberrant payment patterns. The most aberrations were found in Miami-Dade, an area that has become well-known as a hotbed of Medicare fraud. The results regarding Miami-Dade and 23 other counties should invite the attention of the healthcare fraud task force of HHS and the U.S. Justice Department, the report concluded.

The CMS makes outlier payments beyond the standard rate under Medicare's prospective payment system for unusually expensive home care. Outlier payments on average account for 7% of home-health payments, but they made up nearly 60% of home-health payments in Miami-Dade. Miami-Dade also was home to 25 of 29 home-health providers nationwide that received more than $100,000 in outlier payments.

A new CMS rule effective Jan. 1 will cap outlier payments at 10% for any individual home-health agency, and the CMS is taking additional steps to address the apparent abuse, including visits to beneficiaries to ensure they qualify for home-health services, suspending providers responsible for unusually high outlier claims and more tightly controlling enrollment of home-health providers.

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