Home care un­der feds’ fraud mi­cro­scope

Modern Healthcare - - NEWS - By Lisa Schencker

Fac­ing an epi­demic of Medi­care fraud in the home-care in­dus­try, the fed­eral gov­ern­ment is putting a hold on ap­prov­ing new home-care providers in some ar­eas of the coun­try, cap­ping cer­tain types of pay­ments, and us­ing more so­phis­ti­cated data analy­ses to un­cover foul play. Those de­ci­sions have support from a lead­ing home-care trade group.

About half of the Jus­tice Depart­ment’s health­care fraud caseload in­volves home care, said Peter Carr, a Jus­tice Depart­ment spokesman. Wil­liam Dombi, a vice pres­i­dent at the Na­tional As­so­ci­a­tion for Home Care and Hospice, said he’s see­ing a new indictment or con­vic­tion nearly ev­ery week.

Home care, durable med­i­cal equip­ment and men­tal health­care are the three big­gest ar­eas for health­care fraud, said Marc Smolon­sky, a con­sul­tant who works on fraud is­sues. Home care is an easy tar­get for fraud­sters, who can bill Medi­care for many types of ser­vices un­der the um­brella of home care. “Once you have ac­cess to ben­e­fi­cia­ries, you can sub­mit all sorts of bills us­ing their ben­e­fi­ciary num­bers,” he said. The home-care in­dus­try has been the fo­cus of nu­mer­ous in­ves­ti­ga­tions, set­tle­ments and judg­ments. That ac­tiv­ity is re­lated to the pro­lif­er­a­tion of home-care agen­cies and in­creased scru­tiny by fed­eral pros­e­cu­tors, ex­perts say. In 2010, 1 in 4 home-care agen­cies had ques­tion­able billings, ac­cord­ing to a 2012 study by HHS’ Of­fice of the In­spec­tor Gen­eral.

“Home health­care is un­der the mi­cro­scope now,” said Mark Sil­ber­man, a part­ner with law firm Duane Mor­ris, who rep­re­sents home-care agen­cies. “I have no rea­son to be­lieve those ef­forts won’t con­tinue.”

The CMS has stopped ap­prov­ing new agen­cies for gov­ern­ment pay­ment in the Chicago, Dal­las, Detroit, Fort Laud­erdale, Fla., Hous­ton and Mi­ami ar­eas. Dombi’s group has asked the gov­ern­ment to limit the per­cent­age of rev­enue any one agency can get from Medi­care out­lier pay­ments. The Pa­tient Pro­tec­tion and Af­ford­able Care Act caps that fig­ure at 10% of to­tal pay­ments.

Many cases in­volve al­le­ga­tions of kick­backs paid to re­cruiters. Agen­cies are not al­lowed to pay re­cruiters to bring in pa­tients for ser­vices paid for by the fed­eral gov­ern­ment.

They some­times break the law un­in­ten­tion­ally, such as by set­ting up a bonus pro­gram for em­ploy­ees who re­fer pa­tients, said Amanda Bar­bour, a lawyer with But­ler Snow, who rep­re­sents home-care com­pa­nies.

“This is some­thing that’s re­ally go­ing to be scru­ti­nized,” she said. “So you should re­ally just ex­pect some­one’s go­ing to come knock on your door one day.”

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