Home Health & Hospice Week

Medicare uses 5 data measures to identify providers for scrutiny.

If you serve a lot of patients with a primary diagnosis of diabetes or hypertension, you may have wound up on the feds’ radar.

Why? In a new report, the HHS Office of Inspector General identifies five characteristics commonly found in OIG-investigated cases of home health fraud — high percentage of:

1. episodes for which the beneficiary had no recent visits with the supervising physician;
2. episodes that were not preceded by a hospital or nursing home stay;
3. episodes with a primary diagnosis of diabetes or hypertension;
4. beneficiaries with claims from multiple HHAs; and
5. beneficiaries with multiple home health readmissions in a short period of time.

The OIG used these characteristics to identify 562 home health agencies and 4,500 physicians “that were statistical outliers with regard to those characteristics in comparison to their peers nationally,” it says in the report. That’s about 5 percent of HHAs nationally.

Microscope: “Because these providers differ considerably from their peers with respect to common fraud characteristics — often by substantial margins — they warrant further scrutiny to ensure the integrity of the Medicare home health benefit,” the OIG urges in the report. “OIG will conduct investigations and audits of these providers and/or refer them to CMS for followup, as appropriate,” the watchdog agency pledges.

The OIG also used its data to identify 27 potential fraud hotspots in 12 States (Arizona, California, Florida, Illinois, Louisiana, Michigan, Nevada, New York, Oklahoma, Pennsylvania, Texas, and Utah). The hotspots included the areas that the HEAT Strike Force teams already have targeted, but also some new areas such as Provo, Utah and Ada, Okla., the OIG notes.

Note: See the report at http://oig.hhs.gov/oei/reports/oei-05-16-00031.pdf.