OIG Reports on Home Health Care Fraud

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Person Wearing Blue Sterile Gloves - setting a good example, representing healthcare fraud

The U.S. Government is stepping up enforcement efforts against home health services fraud according to an Office of the Inspector General (OIG) alert recently published.

In a separate June 2016 report from OIG, Medicare estimates that it spent approximately $18.4 billion to reimburse more than 11,000 home health agencies. Of that amount, the Medicare Fee-for-Service 2015 Improper Payment Report estimates that there were more than $10 billion (50+%) in improper payments due to services that were not medically necessary, not actually provided, or lacked sufficient documentation.

OIG analyzed the data in the cases it has investigated and found five common characteristics:

1. High percentage of patients with no recent visits to the supervising physician.
2. High percentage of patient care not preceded by a hospital or nursing home stay.
3. High percentage primarily diagnosed with diabetes or hypertension.
4. High percentage claiming services by multiple home health agencies.
5. High percentage with multiple readmissions over a short time frame.

OIG noted that home health fraud commonly involves paying recruiters to collect Medicare numbers for fraudulent billing and colluding with supervising physicians (often known as medical directors) to induce an eligibility certification (perhaps through kickbacks).

OIG also performed an outlier analysis to identify geographies where there could be a large volume of fraud. It identified 27 hotspots located in 12 states, including Florida, Texas, California, Michigan and our own state of Pennsylvania. It noted that several cities that are already in a home health moratorium area and targeted by HEAT Strike Force teams, including Houston, Dallas, Miami, Detroit, Chicago and Detroit are among the hotspots identified.

Cities that have not been the focus of anti-fraud efforts but identified by OIG included Las Vegas, Orlando, San Diego and Phoenix.

The False Claims Act offers home health whistleblowers the opportunity to report cases of health care fraud and earn a reward of between 15 and 30 percent of the amount recovered from the lawsuit by the U.S. Government. Among the things that can be reported are the failure to perform a face to face doctor visit, false certification of homebound, services billed but not actually performed, or services that were not medically necessary for the patient.

For additional information about fraud in the home healthcare industry, please contact one of our False Claims Act attorneys.