Medicare abuse and home healthcare

In 2017, a Dallas physician and three home health agency owners were found guilty for their roles in a $375 million home health care fraud scheme. This is just one example out of hundreds of criminal and civil actions investigated by the Office of Inspector General.

Medicare paid an estimated $41.1 billion (11 percent of Medicare dollars) incorrectly in 2016, including $7.7 billion in improper payment for home health services and supplies. The majority ($7.4 billion) of these improper payments for home health services and supplies were due to insufficient documentation to support home health services. 

This article is from the 4/10/18 issue of Medical Economics.

Fraud vs. abuse

Medicare fraud is when someone intentionally deceives Medicare or falsifies information when billing Medicare. Although cases of Medicare fraud do occur, few physicians will intentionally commit Medicare fraud in their careers. More commonly, physicians unintentionally commit Medicare abuse because of gaps in education and training. 

Medicare abuse is when systemically poor medical practices and procedures result in unnecessary costs to Medicare. Examples of abuse include repeated duplication of services, failing to discontinue services even when they are no longer necessary and providing unnecessary medical services or equipment. Referral to home health care services when it is not medically necessary is an example of Medicare abuse. Penalties of Medicare abuse include exclusion from participation in federally funded healthcare programs, fines and possible imprisonment.

Appropriate documentation

Appropriate documentation is critical when billing Medicare for home health services. There are several criteria that must be met and clearly documented. 

Providers eligible to certify the necessity of home health services must be Medicare enrolled Doctors of Medicine, Doctors of Osteopathic Medicine, and Doctors of Podiatric Medicine (for claims relative to their scope of practice.

Face-to-face encounter

The patient and provider must have a face-to-face encounter related to the primary reason the patient requires home health services. This encounter must take place within 90 days prior or 30 days following the start of home health services. The face-to-face encounter may be performed by:

The certifying physician who is establishing and reviewing the plan of care that requires home health services.  

The physician who cared for the patient if a patient is admitted to home health services directly from an acute or post-acute care facility.

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Nurse or nurse practitioner that collaborates with the certifying physician or doctor from the acute or post-acute care facility.

Certified nurse midwife or physician assistant under the supervision of the certifying physician or physician from the acute or post-acute care facility.

The patient must be confined to the home, such that leaving the home is infrequent and requires considerable effort. This includes individuals who need the aid of a supportive device or another individual to leave their residence, or have a condition that prohibits them from leaving their home. 

The patient must need a skilled service such as skilled nursing, physical therapy, speech therapy, or occupational therapy. 

The provider must certify that the patient is eligible by signing and dating the certification.

Review the care plan

After 60 days, the provider must review the plan of care and determine whether home health services are still required. An estimate of the continued duration of skilled services is required.  

Next: How to protect yourself

How to protect yourself

At this time, Medicare does not have a policy that requires providers submit a specific form to Medicare for home health services. Providers and institutions may choose to develop policies that ensure all the criteria for ordering home health services are fulfilled. The creation of such guidelines will help medical practices protect themselves from partaking in Medicare fraud, waste, and abuse. 

The first step in policy development is education of healthcare providers and staff. It is recommended to start with an overview of healthcare fraud and broader program integrity (PI) issues including fraud and abuse laws and how various organizations are responding to PI issues. Next, preventative strategies to improve PI including protecting medical identities should be discussed. Finally, education should be aimed at documentation and billing best practices. Healthcare providers and staff must also be aware of how and when to report inappropriate activities, and the consequences of not complying with Medicare fraud and abuse laws.

Providers and schedulers must create a policy that all home health service referrals must be initiated at a face-to-face encounter with an appropriate provider. At that encounter, a plan for reviewing the plan of care within 60 days must be solidified. These encounters may be a second face-to-face encounter, or a discussion via phone or e-mail. 

A standardized form should be developed to ensure all components are included when billing for home health services. This form should include:

Note title (e.g. “Home Health Face-to-Face Encounter”)

Encounter Date

A brief narrative describing why the patient is homebound

A brief narrative describing why skilled services are necessary

Signature of the certifying physician, including date of signature

The policy should be publicly posted for patients to review, along with information for patients so they may report policy violations. Finally, a system must be in place to continuously enforce and review the policy. A compliance committee may be tasked with enforcing disciplinary guidelines for not complying to the policy, as well as conducting continuous internal monitoring and periodic review of the policy. 

Establish a policy

Medicare fraud is a widespread problem in the United States and includes improper billing and documentation when ordering home health services. In order to ensure claims are appropriate, physicians should be aware of which patients are eligible for home health services and the associated documentation that should be submitted to support the claim. Establish a policy to ensure providers are adequately informed on appropriate Medicare billing for home health services would be beneficial. Developing a form for the policy that states the minimum required documentation for Medicare home health services and is available to all providers would ensure that each claim meets the requirements for Medicare billing. An established policy is a crucial step toward protecting your medical practice from unintentionally partaking in Medicare fraud and abuse.