Fraudulent billing involving home health services is not new, however in the past year, it has certainly gained more media attention. Starting with the Qui Tam case involving Maxim Healthcare, whereby a New Jersey disabled veteran’s persistence and diligence helped bring about a settlement of approximately $150 million. Also, earlier this year the government brought down Dr. Jacques Roy, responsible for the single largest fraud perpetrated by one doctor, and estimates that his actions accounted for nearly $375 Million in fraudulent claims [1].
Typically, these types of cases involve billing for services not rendered and billing for services that are not medically necessary. Many different scams are present in the Home Healthcare industry including:
- Inflating the hours spent with patients;
- Billing for days when a patient is not seen;
- Services provided by a non-qualified individual such as Nursing Aides, but billing as if they were rendered by a Registered Nurse;
- Performing non-necessary services like house cleaning and billing for skilled services;
- Providing simple services such as insulin injections when the patient is able to perform the services themselves;
- Kickback schemes to physicians to make false certifications for patients to receive care.
According to 2009 Census statistics, Home Health Care (HHC) expenditures totaled over $68 Billion dollars [2]. Using the NHCAA estimates that anywhere from 3 to 10 percent of all healthcare expenditures are fraudulent [3] this means anywhere from 2 to 6 billion dollars are spent each year on fraudulently billed Home Healthcare services. Home health care is such a target for fraudsters that CMS recently imposed a moratorium to temporarily ban new home health agencies in Miami-Dade and Monroe Counties in Florida [4].
Unfortunately, identifying and proving HHC fraud is not an easy task. Providers and agencies often doctor and forge medical records, making medical record reviews unreliable. Additionally, home health records are often voluminous and can prove to be a large review if many patients are involved. When medical records are reviewed, investigators should look out for cloned records, pay attention to the credentials of the providers signing the daily treatment sheets, and ensure the dates of service billed on a claim match what is in the record, among other things.
Out of the Box Thinking
Some other things investigators can include in their investigations include:
- Pull a member sample and conduct member outreach to determine what types of services are being rendered;
- Review Referring Provider data to look for patterns that could reveal potential kickback schemes;
- Conduct outreach to member’s Primary Care Physicians to determine if they are aware their member is receiving Home Health Care and if it is necessary.
For Medicare and Medicare Advantage plans, physicians can bill for the initial certification and re-certification for the Home Health services using HCPCS Codes G0179 and G0180. Investigators should data mine for these codes – providers billing an excessive number of these codes could be suspect for kickback involvement.
FWA detection software like PostShield™ enable users to quickly identify suspect providers billing these codes. Contact Healthcare Fraud Shield if you would like more information on how to data mine for home health services.
[1] US Department of Justice, Press Release
[2] US Census, Health and Nutrition, Health Expenditures, Table 138
Healthcare Fraud Shield 