Stay alert for home health, Medicare fraud

Home health services are convenient and invaluable to homebound individuals who need skilled medical care services provided to them directly in their own homes. Because Medicare covers home health services, they are an extremely lucrative opportunity for scammers and fraudulent care providers looking to make a buck.

Medicare provides home health benefits to individuals who have been deemed homebound by their physicians, meaning they cannot leave their homes without assistance to obtain services elsewhere, and who require skilled nursing services to treat an injury or illness. The requirements for Medicare coverage — 1. to be homebound, 2. to have a plan of care and 3. to need skilled care — must be prescribed by your doctor.

It is important to remember anything that Medicare pays for must be medically necessary, which means you should always work with a trusted doctor (ideally your primary care physician, not a doctor from the home health agency) to order any service, equipment or test that you need. Home health care is no different.

Should your doctor prescribe home health care for you, you should choose a Medicare-certified provider who will work with your physician to create a specific plan of care. The plan of care will detail the services that are to be provided by the home health agency and should be shared with you so you can ensure you are receiving your care as prescribed (i.e. frequency, duration, type). The home health agency will bill Medicare for the services provided under your plan of care, and when you check your Medicare Summary Notice (MSN), you will see a charge for home health services for the time period in which you received them.

There are two common home health fraud examples: In the first example, you receive no services at all. In the second example, you receive services that are different than what is billed or that you are not qualified to receive.

In the first case, a scammer gets your Medicare number somehow. Maybe they call and say they can give you something for free if you give them your Medicare number. Or maybe they call saying they need to verify your Medicare number.

Once a scammer has your Medicare number, they can falsify any documents they send to Medicare. When Medicare reviews these falsified claims, it seems like you are in need of and are actually receiving home health services. In fact, you are not receiving these services at all. If you read your MSN and see billing for services you are not receiving, you should let Medicare know.

In the second case, a home health agency calls or visits your home (they may have gotten your name and address from a presentation or health fair). You are offered free services, like checking your blood pressure, running tests, cleaning your house or buying groceries, and a representative may come to your home a few times to do these things. However, your doctor never ordered these tests, these are not any of the legitimate home health covered services, and you are not homebound. To get paid for these services, the home health agency submits false documents to Medicare that make it seem as if they provided skilled nursing services.

If you read your MSN, you will see services that match when a representative was in your home, but the description may sound more complicated than simply taking your blood pressure. You also may see that the agency continues to bill Medicare after they stopped coming to your home.

The keys to avoiding fraud in either example are to talk to your doctor and read your MSN. You should have your own trusted doctor with whom you can discuss any services you need or are receiving. Some home health agencies have doctors on staff, but it is important to work with your independent primary care doctor.

For help reading your Medicare Summary Notice or if you find that your Medicare account was billed for anything that you did not receive, report this to the Texas Senior Medicare Patrol at 1-888-341-6187. You also can call the BBB Education Foundation at 713-341-6141 with any questions or concerns about home health providers.

Melissa Ramsey is the BBB Education Foundation columnist. For more information, call 713-341-6141.