It’s a reality of life that health care costs are continually on the rise. While a huge aging population is certainly a major contributing factor, far too much of these increases are a direct result of Medicare fraud. Each year more than $60 billion is lost to Medicare fraud, waste and improper payments. That’s more than 10 percent of Medicare’s entire budget.
It’s estimated that 500 home health agencies (about 5 percent of the total) show signs of fraud each year.
With the federal government stepping up fraud enforcement, it’s never been more important to do careful, diligent work to avoid raising any red flags that could lead to an investigation. Here are five things to look out for to make sure you and your staff aren’t incorrectly put under additional scrutiny for fraud:
- Episodes of care during which a beneficiary had no recent visits with the supervising doctorsIf a beneficiary doesn’t have a claim for an in-person visit with their supervising physician within the past 180 days preceding the start of the episode, anything billed may raise some eyebrows. A period this large often indicates the supervising physician didn’t appropriately evaluate the beneficiary’s medical condition before certifying eligibility for home care. This is often a red flag that fraudsters are simply trying to collect Medicare dollars.
- Episodes of care not preceded by a hospital or nursing home stay
While there are scenarios where this is acceptable, beneficiaries who lack claims for hospital inpatient stays or SNF stays with a discharge date in the 30 days preceding the start of the episode, are much more likely to be the recipient of unnecessary home health care. Be aware of how many beneficiaries you have who fall into this group, and work to keep those numbers minimal.
- Episodes of care with a primary diagnosis of diabetes or hypertensionThe Office of the Inspector General has discovered through past investigations that agencies providing medically unnecessary care typically have a disproportionately high number of patients with these conditions as their primary diagnosis. Although there isn’t anything wrong with having a high number of these patients, be aware that it may open you up to increased scrutiny.
- Beneficiaries with claims from multiple agenciesFraudsters routinely move beneficiaries from agency to agency to avoid suspicion and obtain more favorable financial arrangements for fraudulent billing. By keeping track of your number of beneficiaries with claims from other agencies, you can make sure the number isn’t disproportionately high.
- Beneficiaries with multiple home health readmission in a short timeThis is a tactic fraudsters use to hide long periods of care by discharging and then readmitting a beneficiary. While situations exist where a beneficiary may require quick readmission, be aware that it may be viewed with suspicion.
With fraud numbers continuing to escalate in the home health industry, agencies should take steps to minimize risks. By taking these five fraud indicators into account with your compliance reviews and audits, you’ll be able to quickly identify any of your numbers that are outliers. If you discover problems, you can conduct your own investigation to determine all services were medically necessary and if any claims may have been improper. If you identify mistakes, your agency is allowed to report them and refund the money to Medicare. This will result in a much more favorable outcome than if the mistake is caught by the Federal government.