Fraud and Abuse
I want to call your attention to an article in this issue about an important topic – Medicare fraud in home care. The Office of Inspector General looks for outliers in the following five areas: no recent visit with the supervising physician, episodes of care not preceded by a hospital or nursing home admission, a primary diagnosis of hypertension or diabetes, claims from multiple agencies for the same patient, and multiple home health readmissions in a short time frame. Fortunately, only 5% of agencies in the United States are outliers in two or more of these areas. While 5% might seem low, the problem of homecare fraud is substantial, with estimates of $10 billion in improper payments made it 2015 (Schencker, 2016). The Centers for Medicare and Medicaid Services have identified areas of the country that appear to be “hot spots”. These areas are: “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.” (Schencker). No one knows why certain geographical areas become hotspots for fraud, but the Chicago area is so notorious, the federal government ordered no new home care agencies in six counties (Sachdev, 2016).
Without further investigation into the practices of these outlier agencies, we don’t know how many of them are actually committing fraud. There are reasonable explanations that additional scrutiny will hopefully reveal in some cases. The health care system in the United States is notable for being fragmented and reactionary. The industry has responded by being more proactive, so admissions without a hospital stay could represent an attempt to prevent costly hospitalizations. In any event, it is wise for agencies to examine their own statistics in these areas and be prepared for scrutiny by the Office of Inspector General. I urge you to read the article by authors Clark and George.
Another article in this issue is about best practices in hiring and developing direct care workers, also known as personal care assistants. As with any group of workers, most are honest, devoted and provide great care for low wages. But, as the demand for these workers has and continues to increase, the Office of Inspector General is investigating many instances of fraud and abuse involving personal care workers. Patients with personal care workers have been found neglected, filthy, dehydrated, and malnourished. One young woman with severe autism was found outside, frozen to death. Caregivers have been known to not show up at the home for a week at a time, and even to be on vacations when they are being paid to care for these vulnerable individuals (Kaiser Health News, 2016). Personal care workers, or direct care workers are paid by the federal government (through programs administered by each individual state) to care for Medicaid patients requiring assistance with activities of daily living – bathing, grocery shopping, meal preparation and eating. Author Lynda Stear provides best tips for hiring, supervising and developing the potential of this important group of workers.
The Office of Inspector General is justifiably devoting much attention to home care as the demand for care and subsequent costs increase every year. We know that people are increasingly hoping to “age in place”. We owe it to our patients to ensure the availability of funding for home care for the long-term. It is up to each one of us to be alert to fraudulent billing practices and abuse of patients. Don’t let a relatively small group of dishonest and unscrupulous individuals upend a vital segment of the care continuum.
Maureen Anthony, PhD, RN
Kaiser Health News (2016). Seniors Suffer Amid Widespread Fraud by Medicaid Caretakers. Retrieved from http://khn.org/news/seniors-suffer-amid-widespread-fraud-by-medicaid-caretakers/
Sachdev, A. (2016, June 22). Chicago a hot spot for home health fraud. The Chicago Tribune. Retrieved from http://www.chicagotribune.com/business/ct-home-health-fraud-0623-biz-20160622-story.html.
Schencker, L. (2016). About 5% of home healthcare agencies show potential signs of fraud. Retrieved from http://www.modernhealthcare.com/article/20160623/NEWS/160629955.