Government spending on healthcare and the cost of healthcare in general has risen dramatically in the past few decades. With costs continuously escalating, the federal government has more incentive than ever before to root out the fraud and corruption in the healthcare sector that costs taxpayers billions of dollars each year.
Medicare’s home health benefit provides payment to a Home Health Agency (HHA) for care given over a 60-day period. To qualify for the home health benefit, patients must be certified as “homebound,” meaning that they must be unable to leave their home except for occasional short trips for medical care. In addition, home healthcare must be well documented, administered according to a physician-established plan of care, and be medically necessary for the patient’s unique condition. The care provided must also fall under one of the approved categories:
The amount of payment made to the HHA is determined by Medicare according to the Outcome Assessment Information Set (OASIS) form, which lists the number of visits and level of need for the patient. Payment amounts also depend on the Home Health Resource Group (HHRG) to which the patient is assigned under Medicare. Because payment is determined based on information submitted by the party receiving the payment (the HHA), there is a significant opportunity for HHAs to commit Medicare fraud to increase the amount of payments they receive. This payment issue was a focus of the Amedisys settlement, which was the largest home healthcare settlement in the history of the FCA, handled by Kenney and McCafferty in 2014.
Types of Home Healthcare Fraud
Home healthcare fraud is typically perpetrated by submitting claims in a way that is not compliant with the Medicare home health benefit requirements or by falsifying information reported to Medicare in order to receive more money for a patient. For example, the HHA may fail to properly certify and document the medical needs and homebound status of the patient with a physician. HHAs may also bill Medicare for services other than those approved under the home health benefit.
Another common practice is upcoding, reporting the patient’s condition as more severe to qualify for greater compensation. In addition, financial arrangements between HHAs and referring or certifying physicians may be in violation of the Stark Statute and/or the Anti-Kickback Statute.