Home Health & Hospice Week

New tools to detect and curb fraud on deck.

What your patients have to say about your home care services may determine whether you land in Medicare authorities’ fraud crosshairs, under an ongoing fraud-fighting demonstration.

In the Feb. 5 Federal Register, the Centers for Medicare & Medicaid Services published a request for Office of Management and Budget approval to continue collecting data for the Medicare Probable Fraud Measurement Pilot. The pilot “would establish a baseline estimate of probable fraud in payments for home health care services in the fee-for-service Medicare program,” CMS explains in the notice.

“Documenting the baseline amount of fraud in Medicare is of critical importance, as it allows officials to better evaluate the success of ongoing fraud prevention activities,” the HHS Office of Inspector General noted in its Health Care Fraud And Abuse Control Program Report for 2014 released last year (see Eli’s HCW, Vol. XIV, No. 16).

Background: CMS developed the methodology for the program in 2011, then developed the measurement tools for the pilot in 2012 and collaborated with government partners on the strategy for implementation, the OIG noted in the HCFAC report. CMS received OMB approval in May 2013. “CMS will begin collecting data on … and have an estimate of probable fraud within HHAs in 2015,” the OIG said in the report.

Now CMS is asking to extend its data collection for the pilot. But the untested methodology has some serious problems, believes financial expert Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif.

“CMS and its agents will collect information from home health agencies, the referring physicians and Medicare beneficiaries selected in a national random sample of home health claims,” CMS says in the Federal Register notice. “The pilot will rely on the information collected along with a summary of the service history of the HHA, the referring provider, and the beneficiary.”

Relying on information provided by frail, elderly beneficiaries is folly, Boyd insists. Medicare tried a similar tactic back in the 1990s, and patients often couldn’t recall visits, confused nurses with aides, and made other mistakes. “Mass confusion resulted as [the MAC] accused HHAs of fraud or mistakes in billing,” Boyd remembers.

Getting referring physicians to respond to information requests in a timely manner will also prove incredibly difficult, Boyd expects. That’s particularly true in the face-to-face era of already burdensome physician paperwork. If docs are “nonresponsive will CMS consider that as fraud or delete [it] from the statistic?” Boyd asks.

Plus: As with any process, billing and paperwork errors are bound to occur from time to time.

Under the pilot, “are these actions going to result in the claim being considered fraud?” Boyd queries. Boyd urges CMS to focus more resources on preventing bad actors from entering the Medicare program as opposed to pursuing fraud fighting procedures that will result in questionable data (see story, below). “Some of those accused of fraud should have merited better review at the initial stage of becoming certified,” Boyd tells Eli.

Note: See the notice at www.gpo.gov/fdsys/pkg/FR-2016-02-05/pdf/2016-02277.pdf. Interested parties can comment on the notice until April 5.