Healthcare Fraud and Abuse is an ever growing problem.  The Federal government has taken several steps in its enforcement efforts to cut down on health care fraud.  It is estimated that health care fraud costs the United States about $80 billion per year.  And it continues to rise in an alarming manner, as total U.S. health care spending continues to rise, currently topping $2.7 trillion.

In the last year, spending on home health care has increased over 5 percent from previous years.  Since 2000, the senior population has increased by 15.1% versus 9.7% for the population as a whole.  According to the 2014 FBI press release, these trends led to Medicare reimbursements for home-based care totaling $18.4 billion in 2011 and state Medicaid program reimbursements of $12.7 billion for beneficiaries’ personal-care services.  According to the Centers for Medicare & Medicaid Services (CMS), approximately 12 million individuals receive in-home care, much of which is provided by more than 11,600 Medicare-certified home health agencies.

In the past year, federal and state law enforcement officials have increased their efforts in combatting fraud and abuse in the home health industry.  This has included targeting providers referring patients for home care services, owners of home care agencies, nurse staffing agencies, and personal care aides across the country.  One of the largest enforcement efforts this year has been in the Washington, DC area, culminating in the arrest of over 20 individuals accused of fraudulently billing the District of Columbia’s Medicaid program.  Similarly, in Dallas, Texas, federal indictments were handed down against hundreds of home health agencies accused of Medicare Fraud that was mastered-minded by a single physician.  As noted in the indictment, the agencies wrote “visit notes to make it appear that they provided skilled nursing to the Recruited Beneficiaries when no skilled nursing was provided.”

Because fraud and abuse enforcement by both Federal and State agencies is increasing, effective compliance programs for home health companies are needed to better distance the home health company from the fraud activities.  At minimum, home health care agency’s compliance programs should include:

  • The development and distribution of written standards of conduct, as well as written policies and procedures that promote the home health agency’s commitment to compliance and address specific areas of potential fraud;
  • The designation of a compliance officer and other appropriate bodies, charged with the responsibility for operating and monitoring the compliance program;
  • The development and implementation of regular, effective education and training programs for all affected employees;
  • The creation and maintenance of a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation;
  • The development of a system to respond to allegations of improper/ illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or Federal health care program requirements;
  • The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas; and
  • The investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals..