National Fraud “Hot Spots” Revealed in Largest-Ever Operation Announced by US DOJ

The US Department of Justice announced that 301 individuals have been charged with falsely billing Medicare a total of approximately $900 million in what is being called the largest coordinated Medicare fraud take down in history.

Home health services were among a list of services involved in the fraud schemes that also included physical and occupational therapy, durable medical equipment (DME) and prescription drugs. In the process, the HHS Inspector General released a data brief titled “Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases.”

That data brief reveal some trends in outlier patterns among home health agencies and affiliated physicians, but also identifies 27 “hot spots” in 12 states where home health care fraud is prevalent. Massachusetts is not among the states shown in the map below where much of the home health fraud activity is occurring.

Recently, Massachusetts has been included in a planned “pre-claim review” demonstration starting “no earlier” than January 2017 that will, according to CMS, test whether such a process improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies. Among the five states involved in the demonstration, Massachusetts is the only one not on any target list for the Medicare Fraud Task force known as HEAT (Health Care Fraud Prevention & Enforcement Action Team). For many years, the Home Care Alliance has repeatedly advocated for a temporary moratorium on new Medicare home health providers in response to recent growth in the number of new agencies, but such efforts have been denied by Medicare.

2016 HHA Fraud Hotspots

According the to HHS Inspector General, these are areas where characteristics commonly found in OIG-investigated cases of home health fraud were prevalent. The report states that “many of these hotspots are areas already recognized as having high rates of Medicare fraud, which suggests that home health fraud in these areas is an ongoing concern and that enforcement and program integrity efforts should continue.”

HCA Statement on Indictment of Waltham Home Health Agency Owner

Home Care Alliance of Massachusetts Decries Fraud Renews Call for Stricter Oversight or New Agencies, Moratorium

Boston, MA – The arrest on September 16th of the owner/proprietor of a Massachusetts home health agency on charges of defrauding the federal Medicare program should be seen as a wake-up call to federal and state officials that unlimited expansion of home health agencies is threat to the Medicare program and its beneficiaries.  The Home Care Alliance applauds the efforts of the federal Office of the Inspector General in identifying the aberrant behavior of this agency and reiterates its call for the federal government to do more to target abusive agencies.

“Home health agencies in Massachusetts work hard to comply with all federal and state rules and are an integral part of building a more patient centric, cost effective health care system,” said Patricia Kelleher, Executive Director of the Home Care Alliance of Massachusetts, a trade association for more than 190 Medicare certified and private pay home care agencies.  “We have been calling for more directive enforcement efforts aimed at outlier agencies, as opposed to blanket enforcement that burdens the high quality, highly ethical providers.

The Home Care Alliance has met with staff at CMS regularly over the past four years urging that there be: 1) More active enforcement of existing Medicare program rules, and 2) A more rigorous set of rules for entry into the industry in order reduce the growth of unqualified agencies.

The Alliance wrote to Health and Human Services Secretary Kathleen Sebellius in 2011 and 2012 urging her to immediately place a moratorium on the enrollment of new home health providers into the Medicare program. The Medicare Payment Advisory Commission (MedPAC) also made this recommendation in their March 2011 report to Congress, and the Secretary was granted the authority by the Patient Protection and Affordable Care Act to suspend payments to providers or establish a moratorium on new provider enrollment.

The Alliance has also filed state legislation to require any new agency to file and be granted a state “certificate of need” before applying for federal Medicare certification.

“The home health agencies in Massachusetts have worked hard to gain the trust of patients and families, as well as our physician and hospital partners,” said Beverly Pavasaris, President of the Home Care Alliance and Executive Director of the Brockton VNA. “Agencies such as mine, with more than 100 years of proving home based care, will not sit idly and let our good work and reputation be damaged by individuals intent on committing fraud.” Continue reading “HCA Statement on Indictment of Waltham Home Health Agency Owner”