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The Office of Inspector General Focuses on Home Care Again

The Office of Inspector General (“OIG”) issued two documents that again point to fraud and abuse in home health care. The documents also highlight the role of physicians as “gate keepers” in authorizing home health services and facilitating improper billing across the care spectrum. 

The first document is the “Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases” in which the OIG examined 2014—2015 Medicare home health claims data and identified certain home health agencies (“HHAs”), supervising physicians, and geographic areas associated with Medicare claims having “characteristics similar to those observed by OIG in cases of home health fraud.”  On page 2 of the document five common characteristics found in OIG-investigated cases of home health fraud are listed:

  1. High Percentage of Episodes for which the Beneficiary had No Recent Visits (6 months) with the Supervising Physician
  2. High Percentage of Home Health Episodes that were Not Preceded by a Hospital Or Nursing Home Stay (Within 30 Days)
  3. High Percentage of Episodes with a Primary Diagnosis of Diabetes or Hypertension
  4. High Percentage of Beneficiaries with Claims from Multiple HHAs (3 or more HHAs within 2 years)
  5. High Percentage of Beneficiaries with Multiple Home Health Readmissions in a Short Period of Time (under 2 years)

Starting on page 6, the report highlights 27 geographic areas in 12 states that are geographic “hotspots” for the five characteristics commonly found in home care fraud cases. In Figure 2 on page 7, and in Table A-1 on page 13, the report identifies New York as an area that may warrant greater scrutiny.

In a second document, “Alert: Improper Arrangements and Conduct Involving Home Health Agencies and Physicians” OIG points out the possible fraud associated with the compensation arrangements between HHAs and physicians, under which the physician, in a position to make referrals to the HHA, is paid to serve as “medical director” at a level above “fair market value,” and without providing bona fide services to the agency.  Some of the activity mentioned included payments for patient referrals, falsely certifying patients as homebound, and billing for medically unnecessary services or for services that were not rendered.

Both documents point to OIG increasing scrutiny, examining any improper arrangements or billing practices.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871