Home Health & Hospice Week

But it wants to put 8 more areas in the enforcement crosshairs.

Fraud and abuse scrutiny is on the rise across the board for home care providers, but the HHS Office of Inspector General is only getting started on its stringent home health and hospice fraud enforcement plan, a new report indicates.

In its 2019 budget justification report, the OIG notes that combating fraud and abuse in the home setting is a top priority in need of funding.

"Home health services, which account for approximately $18 billion in Medicare spending per year, have long been recognized as a program area that is particularly vulnerable to fraud, waste, and abuse," the report says. "Using data analytics, OIG identified four geographic areas - Florida, Texas, and select areas in Southern California and the Midwest - that have large numbers of home health providers with characteristics that OIG determined ... to be suspect. OIG seeks to both reduce fraud, waste, and abuse and enhance program integrity in noninstitutional settings in these four geographic 'hot spots' through outreach, education, audits, evaluations, investigations, and administrative enforcement."

The program is already working, the watchdog agency contends. "OIG efforts ... have contributed to a 5-percent decrease in home health payments in the four geographic hot spots from CY 2015 through CY 2016. Nationally, the decrease in home health spending over this same time was 1 percent," according to the report.

The OIG also touts the success of its Health Care Fraud Strike Force teams. "During FY 2017, OIG's Strike Force efforts resulted in the filing of charges against 186 individuals or entities, 264 criminal actions, 2 civil actions, and $771.5 million in investigative receivables," the agency recounts. The report offers a home health example for Strike Force accomplishments. "An individual who owned and managed three home health agencies in Miami was convicted in a scheme that involved kickbacks to doctors and patient recruiters in return for referrals of Medicare beneficiaries and the purported furnishing of home health services that were not provided or were not medically necessary," the OIG relates.

Lion's share: "Fighting home health services fraud in Medicare and Medicaid is an OIG priority and represents a significant portion of our enforcement efforts," the OIG says. "OIG home health investigations resulted in more than 400 criminal and civil actions and $1 billion in receivables for FYs 2011–2016. OIG investigations continue to identify and address fraudulent payments."

The OIG lists some home health agency "common schemes," including "billing for services that are not needed or not provided or paying kickbacks to recruiters, providers who order or certify the services, and patients." OIG audits have also uncovered "improper payments across a number of risk areas, such as medical necessity and homebound determinations."

Enforcement in home-based services is bound to get tighter, the report indicates. "Program integrity in non institutional settings takes on heightened urgency as consumers increasingly seek and prefer services provided in those settings, including in their own homes. In these settings, OIG has uncovered risks for, and instances of, serious patient harm," the OIG says.

The OIG doesn't let hospices off the hook. "Hospice care provides comfort for terminally ill beneficiaries and supports family and other caregivers; yet OIG has found that hospices frequently fail to meet Medicare requirements for patient care, billing, certification, and licensure. Disturbingly, OIG has also investigated cases of hospice providers enrolling beneficiaries in hospice care without their consent," the agency reports. "In addition to fraud and risks of patient harm, improper payments for these services take a financial toll."

Future plans: With its requested budget, "OIG would develop new recommendations for targeted program safeguards that prevent fraud by bad actors while limiting burden on legitimate providers," it claims. "Through data analytics, OIG would also detect new and emerging fraud schemes, enabling it to monitor trends and migration of known fraud schemes. With this reinvestment, OIG would also add 'boots on the ground' to take appropriate enforcement actions against fraud perpetrators, including building its capacity to respond to the fraud referrals generated by its own analysts."

Those referrals could turn into a lot of home care investigations. "OIG analysts identified more than 500 home health agencies and more than 4,500 physicians with multiple characteristics commonly associated with home health fraud," the report says.

"OIG also identified 27 'hotspots' in 12 States where red flags for home health fraud are prevalent."

Ahead: "With additional resources, OIG would open more criminal, civil, and administrative investigations, as warranted, and conduct more audits and monitoring of suspicious billers. It would also target certain hot spots to conduct site visits of high-risk home health agencies, for example.

Importantly, these efforts would help ensure that consumers are protected and honest providers do not have to compete with dishonest ones," the report concludes.

See the budget request justification at https://oig.hhs.gov/reports-and-publications/archives/budget/files/2019budget.pdf.