Home Health & Hospice Week

Prior auth won’t slow down home care fraudsters, experts contend.

The whole reason Medicare is proposing a prior auth demo for home health services is questionable, according to industry experts.

In the Feb. 5 Federal Register, the Centers for Medicare & Medicaid Services proposes a prior authorization demonstration for home health services in five high-risk states (see related story, p. 50). In the notice, CMS says the law authorizes it to “‘develop or demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by the Social Security Act.’ In accordance with this authority, we seek to develop and implement a Medicare demonstration project, which we believe will help assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among HHAs providing services to Medicare beneficiaries.”

“This demonstration would help assure that payments for home health services are appropriate before the claims are paid, thereby preventing fraud, waste, and abuse,” CMS concludes.

Warning: This demo could be the tip of the iceberg when it comes to burdensome new requirements. “This demonstration is … of concern because it is apparently based on very broad authority that will allow CMS and the MACs to engage in many broad activities in the name of preventing fraud,” cautions Washington, D.C.-based health care attorney Elizabeth Hogue.

The prior auth process won’t be very effective in combating fraud anyway, maintains attorney Robert Markette Jr. with Hall Render in Indianapolis. “It’s not a great anti-fraud tool.” Home care fraudsters are “professional liars,” Markette notes. They will just identify what falsified documents they need to gain approval, “then lie on those too.”

Bad actors “will figure out quickly what’s needed and do it,” Markette predicts. It’s the law-abiding HHAs that will get bogged down in increased paperwork burdens, physician interactions, and payment delays.

Focus On Suspicious Stats

“There are other avenues available to combat fraud in targeted areas” that would work better than a prior auth system, contends billing expert M. Aaron Little with BKD in Springfield, Mo.

For example: “Fraudsters are greedy,” insists industry veteran Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif. “Recent cases disclose the pattern of rapid growth … in ‘services,’ going from little to very much. This can be seen in the claims system and anyone experiencing rapid growth should be subject to greater medical review and some random verification of services.” Skyrocketing utilization and billing were “the tip-off to the Florida outlier problem and the recent Medicare Advantage Medicaid agencies” fraud crack-down in Massachusetts, he adds. “However, in both cases the government should have reacted sooner.”

Beefed up background checks for HHA management during the enrollment and revalidation processes would yield better results, Boyd adds. So would more fully investigating complaints left via mechanisms such as 1-800-HHS-TIPS and 1-800-MEDICARE. “Few if any are investigated, or so it seems,” he says.