More than 500 home healthcare agencies—about 5% of the total—and 4,500 doctors across the country share characteristics that often point to home healthcare fraud, according to a report released by HHS' Office of Inspector General on Wednesday.
According to the Office for Inspector General, home healthcare fraud cases typically involve five characteristics, including high percentages of:
- episodes of care during which a beneficiary had no recent visits with the supervising doctors
- episodes of care not preceded by a hospital or nursing home stay
- episodes of care with a primary diagnosis of diabetes or hypertension
- beneficiaries with claims from multiple agencies
- beneficiaries with multiple home health readmission in a short time
“While there may be legitimate explanations as to why any of these specific (home healthcare agencies) and physicians were outliers on characteristics commonly found in OIG-investigated cases of home health fraud, further scrutiny is warranted,” according to the report.
William Dombi, a vice president at the National Association for Home Care and Hospice, called the information in the report “useful” but said the association has concerns with some of the so-called risk factors for fraud.
For example, some might say that high percentages of episodes of care not preceded by a hospital or nursing home stay is a good thing because it means patients didn't wait for a malady serious enough to warrant a hospital or nursing home stay before seeking home health care.
He said, overall, the report identified a relatively small number of outliers, and he's pleased the Office for Inspector General is helping the CMS develop ways of targeting risk areas.
“It hurts everybody, including home healthcare agencies, when bad things are done,” Dombi said.
Scott Shanker, an attorney with Butler Snow who works with clients on regulatory and compliance issues, said he's surprised the numbers of providers and agencies with risk factors for fraud weren't higher.
“There's been a lot of fraud and abuse in home health agencies for many years, and OIG has continued to seek enforcement for failure to comply with regulations and billing requirements, yet there still appears to be significant amounts of fraud and abuse,” Shanker said. “I'm not sure you're ever going to stop it.”
The report noted that home healthcare fraud has long been an area of concern. In fiscal 2015, the CMS estimated that Medicare made more than $10 billion improper payments to home healthcare agencies.
In response, the CMS has imposed moratoria on new home healthcare agencies in certain areas of the country where fraud was proliferating. Investigations have led to more than 350 criminal and civil actions between 2011 and 2015.
The report also identified 27 hot spots in 12 states where the characteristics of fraud were common. Those hot spots included: Los Angeles and San Diego; Las Vegas; Provo, Utah; Phoenix; Tahlequah and Ada, Okla.; Dallas, San Antonio, Houston, Laredo, Duval County, Rio Grande City, McAllen and Brownsville, Texas; Avoyelles County, La.; Chicago; Detroit and Ogemaw, Mich.; New York City; Philadelphia; and Jacksonville, The Villages, Orlando, Miami-Ft. Lauderdale, Lakeland and Tampa, Fla.
The alert, also issued Wednesday, reminded providers that agencies and doctors entering into compensation agreements for services must ensure those payments are of fair market value and commercially reasonable to avoid running afoul of the anti-kickback statute. It also warned agencies that they must make sure beneficiaries who receive their services are actually confined to their homes and need the services.
The alert noted that recent enforcement efforts have focused on doctors and agencies that defrauded Medicare by illegally paying for patient referrals, falsely certifying patients as homebound and billing for medically unnecessary services or services