Home health care has long been seen as a program area vulnerable to fraud, waste, and abuse with physicians playing a central role. The Medicare home health benefit covers skilled nursing care, home-based assistance, and therapeutic services for qualifying homebound individuals.

Home healthcare represents a significant part of the Medicare program with $18.4 billion paid to more than 11,000 home health agencies (HHA’s) in calendar year 2015. The Centers for Medicare & Medicaid Services (CMS) has estimated that over $10 billion in improper payments was paid in fiscal year 2015 alone. OIG home health investigations have resulted in more than 350 criminal and civil actions and $975 million in receivables for fiscal years 2011–2015.

Physicians act as “gatekeepers” by certifying beneficiaries’ eligibility and managing their care plans. OIG investigations have frequently found physicians to be principal conspirators in home healthcare fraud schemes—for example, by approving medically unnecessary home health care in exchange for kickbacks.

In June 2016, the Office of Inspector General released a nationwide analysis of common characteristics in Home Health Fraud Cases as the result of examining Medicare claims data for calendar years 2014-2015 to identify home health agencies (HHAs), supervising physicians, and geographic areas whose Medicare claims have characteristics similar to those observed by OIG in cases of home health fraud.

The analysis and results (in bold and brackets) centered on the national prevalence and distribution of selected characteristics commonly found in OIG-investigated cases of home health fraud. There were five distinct characteristics common to them:

1. High percentage of episodes for which the beneficiary had no recent visits with the supervising physician [Almost 500 HHAs and more than 16,500 physicians had an unusually high percentage of home health episodes for which the beneficiary had no recent visits with the supervising physician];
2. High percentage of episodes that were not preceded by a hospital or nursing home stay [More than 1,700 physicians had an unusually high percentage of home health episodes that were not preceded by a hospital or nursing home stay];
3. High percentage of episodes with a primary diagnosis of diabetes or hypertension [Almost 500 HHAs and 8,000 physicians had an unusually high percentage of home health episodes with a primary diagnosis of diabetes or hypertension];
4. High percentage of beneficiaries with claims from multiple HHAs [Almost 800 HHAs and more than 7,500 physicians had an unusually high percentage of beneficiaries with claims from multiple HHAs];
5. High percentage of beneficiaries with multiple home health readmissions in a short period of time [Almost 800 HHAs and 4,000 physicians had an unusually high percentage of beneficiaries with multiple home health readmissions in a short period of time].

While the analysis identified a substantial number of providers—more than 500 HHAs and 4,500 physicians—that were outliers compared nationally to their peers, with respect to multiple characteristics commonly found in OIG-investigated cases of home health fraud, it is important to note that the OIG’s analysis did not demonstrate that these outlier providers were engaged in fraudulent activity and that there may in fact be legitimate explanations for any of the specific providers contained in the report.

However, the OIG also said that:

 …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.

Nolan Auerbach & White is committed to working with healthcare whistleblowers to stop healthcare fraud affecting federal programs, including home health care fraud. More information for potential whistleblowers is located on our main website.