In 2017, a Dallas physician and three home health agency owners were found guilty for their roles in a $375 million home health care fraud scheme. This is just one example out of hundreds of criminal and civil actions investigated by the Office of Inspector General.
Medicare paid an estimated $41.1 billion (11 percent of Medicare dollars) incorrectly in 2016, including $7.7 billion in improper payment for home health services and supplies. The majority ($7.4 billion) of these improper payments for home health services and supplies were due to insufficient documentation to support home health services.
Fraud vs. abuse
Medicare fraud is when someone intentionally deceives Medicare or falsifies information when billing Medicare. Although cases of Medicare fraud do occur, few physicians will intentionally commit Medicare fraud in their careers. More commonly, physicians unintentionally commit Medicare abuse because of gaps in education and training.
Medicare abuse is when systemically poor medical practices and procedures result in unnecessary costs to Medicare. Examples of abuse include repeated duplication of services, failing to discontinue services even when they are no longer necessary and providing unnecessary medical services or equipment. Referral to home health care services when it is not medically necessary is an example of Medicare abuse. Penalties of Medicare abuse include exclusion from participation in federally funded healthcare programs, fines and possible imprisonment.
Appropriate documentation is critical when billing Medicare for home health services. There are several criteria that must be met and clearly documented.
Providers eligible to certify the necessity of home health services must be Medicare enrolled Doctors of Medicine, Doctors of Osteopathic Medicine, and Doctors of Podiatric Medicine (for claims relative to their scope of practice.
The patient and provider must have a face-to-face encounter related to the primary reason the patient requires home health services. This encounter must take place within 90 days prior or 30 days following the start of home health services. The face-to-face encounter may be performed by:
The certifying physician who is establishing and reviewing the plan of care that requires home health services.
The physician who cared for the patient if a patient is admitted to home health services directly from an acute or post-acute care facility.
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Nurse or nurse practitioner that collaborates with the certifying physician or doctor from the acute or post-acute care facility.
Certified nurse midwife or physician assistant under the supervision of the certifying physician or physician from the acute or post-acute care facility.
The patient must be confined to the home, such that leaving the home is infrequent and requires considerable effort. This includes individuals who need the aid of a supportive device or another individual to leave their residence, or have a condition that prohibits them from leaving their home.
The patient must need a skilled service such as skilled nursing, physical therapy, speech therapy, or occupational therapy.
The provider must certify that the patient is eligible by signing and dating the certification.
Review the care plan
After 60 days, the provider must review the plan of care and determine whether home health services are still required. An estimate of the continued duration of skilled services is required.