Government Tackles Skyrocketing Scams In Medicare Billing For Home Care

Posted On Wednesday, February 3, 2016

Fraud in the home health care services sector – where Medicare spends $18 billion annually for home health-related services – is officially in the hot seat for government scrutiny.

In a concerted effort to tackle what has been considered rampant fraud, waste and abuse, the Centers for Medicare and Medicare Services extended moratoriums on new ambulance and home health care providers three times since mid-2013. These moratoriums, which the Affordable Care Act authorizes regulators to use, have covered major metropolitan and surrounding areas, including Florida, Illinois, Michigan, Texas, Pennsylvania and New Jersey. Originally, CMS’ justification for the bans included increased levels of fraud and unusually high ratios of providers to beneficiaries. Government attorneys have credited the most recent ban extension of January 2015 towards helping prosecutors address the extensive and time consuming nature of criminally investigating these scams.

Other states like Louisiana, a top five state for average home health payment per Medicare beneficiary, are spotlighting home health-care fraudsters with increasing urgency. Kenneth A. Polite Jr., U.S. Attorney for Eastern Louisiana, has announced that across Louisiana, home health-care schemes have become “the greatest and most significant trend” in health-care fraud in Medicare. As a result, Polite is launching a counteroffensive against these skyrocketing scams.

Louisiana’s most notable indictment emerged in March 2015, when 20 individuals – including not just ringleaders, but management, nurses, doctors, and marketers alike – were charged in a $30 million alleged conspiracy involving a company called Abide Home Care Services Inc. Lengthy sentences and millions in illegitimate payments are being pursued. Other recent takedowns in Louisiana include the indictments of three individuals in connection with an alleged $33 million fraud involving Christian Home Health Care Inc., as well as the indictments of a dozen individuals in connection with an alleged $50 million scam involving Interlink Health Care Services Inc. and other home health companies.

Fundamentally, the intended beneficiaries of the home health care benefit are those individuals who have trouble leaving home due to long-term disability or recent medical procedures. However, home health schemers are marketing and billing this benefit by certifying that at-home visits to patients are necessary, even though these patients are not, in fact, homebound. In addition, these at-home visits are upcoded and billed to Medicare as having required more skilled, complicated, and time consuming services than what is needed or actually performed.

Prosecutors’ tactics in identifying fraudulent upcoding are also increasing in sophistication.  In building a case against Abide, for example, prosecutors used data analytics to establish findings that Abide was a top biller country-wide for several highly specific diagnoses that require steep payments to home health agencies. As Polite’s lead health fraud prosecutor Patrice Sullivan has explained: “The idea that [Abide’s] patient population has a bucketful of [lucrative] diagnoses – it’s even more than an anomaly, it’s statistically impossible.”

Government attorneys are not alone in their mission to crackdown on shady Medicare billing for home care. In Louisiana, the recent cases have been investigated with the help of special a special “strike force,” the FBI, and the U.S. Department of Health and Human Services’ Office of Inspector General.

U.S. Attorney Polite has stated that there is no end in sight for indictments, with several home health indictments pending and more likely to materialize throughout 2016.