CMS Calls Moratorium On Home Healthcare Agencies To Preempt Fraud And Abuse

Once every few months you can catch the Tom Cruise science-fiction thriller Minority Report on basic cable.  Cruise’s character, John Anderton, worked in a special law enforcement division known as “Pre-Crime.”  Police used visions of three special beings known as “precogs” to predict future criminal activity, and arrest the future offenders before they commit an offense.  The Centers for Medicare and Medicaid Services (“CMS”) has brought it’s own version of this enforcement technique to fruition today, using data mining to predict future fraud and abuse.

On January 30, 2014, CMS extended and expanded a moratorium on new home-health agencies and ambulance providers in Florida, Michigan, Texas, Illinois, and Pennsylvania.  CMS Administrator Marilyn Tavenner cited a provision of the Affordable Care Act that permits temporary enrollment moratoria.  CMS based this bold move on statistical analysis of fraud enforcement activity around the country.  Tavenner said she wants to move CMS beyond “pay and chase” and prevent fraud before it occurs in areas of known risk.

For example, Houston, Texas is an outlier in the area of home healthcare.  In that jurisdiction in 2012, the ratio of home healthcare agencies to Medicare fee-for-service beneficiaries was 276% higher than comparison counties.  Our hometown of Philadelphia, Pennsylvania is also on the chopping block.  In 2012, the ratio of ambulance suppliers to fee-for-service beneficiaries in the Philadelphia metropolitan area was 232% higher than comparison counties.  

This current moratorium on new providers lasts for a period of six months and may be extended by notice published in the Federal Register.  We must wait and see whether such bold enforcement actions will represent a sea change in fraud prevention or whether it will be abandoned like “Pre-Crime” in favor of more traditional investigation.

For more information, visit http://goo.gl/jOD8Ut and 42 C.F.R. 424.570.