FRAUD AND ABUSE ISSUES IN HOME HEALTH CARE (FROM SECRETARY'S NATIONAL CONFERENCE ON FRAUD, ABUSE, AND ERROR - PROTECTING THE TAXPAYER'S DOLLAR, P 41-45, 1978 - SEE NCJ-68143)

• NCJ Number: 68150
• Author(s): J LAVOR
• Date Published: 1979
• Length: 5 pages
• Sale Source: Superintendent of Documents, GPO
• Language: English
• Country: United States of America
• Note: NCJ-68150 AVAILABLE ON MICROFICHE FROM NCJRS UNDER NCJ68143.

Annotation

THE NEWNESS OF AND RECENT INCREASES IN EXPENDITURES FOR HOME HEALTH CARE SERVICES HAVE FORCED HIGHER VISIBILITY ON THESE SERVICES AND MORE OPPORTUNITIES FOR FRAUD AND ABUSE DETECTION THAN OLDER MEDICARE PROGRAMS.

Abstract

SERVICES IN THE HOME ARE ALMOST IMPOSSIBLE TO SYSTEMATICALLY SCRUTINIZE. THE ONE-TO-ONE RELATIONSHIP BETWEEN THE PROVIDER AND A CLIENT WHO IS ILL, AND OFTEN VULNERABLE, OLD, AND ALONE CREATES A SPECIAL PROBLEM THAT DOES NOT EXIST IN A GROUP CARE SETTING. FURTHERMORE, SUCH SERVICES HAVE REMAINED UNREGULATED. HOME HEALTH AGENCY INVESTIGATIONS HAVE REVEALED FRAUDULENT OR ABUSIVE PRACTICES SIMILAR TO OTHER PROVIDER AREAS; E.G., BILLING FOR SERVICES NOT RENDERED, MISREPRESENTATION OF SERVICES, DUPLICATE BILLINGS. YET, SINCE FOR MANY YEARS HOME HEALTH SERVICES CONSUMED ONLY 1 PERCENT OF MEDICARE EXPENDITURES, AND ONE-TENTH OF 1 PERCENT OF MEDICAID EXPENDITURES, HOME HEALTH SERVICES HAVE REMAINED LITTLE UNDERSTOOD OR CONTROLLED. REIMBURSEMENT POLICIES HAVE BEEN VAGUE, FISCAL INTERMEDIARIES HAVE NOT SET SPECIFIC LIMITS ON REASONABLENESS OR TYPES OF COSTS ALLOWED, AND LACK CONTROL OVER COSTS AND LIMITS ON PROPRIETARY AGENCIES HAVE PERMITTED THE INFLUX OF THE PRIVATE NOT FOR PROFIT HOME HEALTH AGENCY. HOME HEALTH AGENCIES THAT SERVE ONLY MEDICARE BENEFICIARIES ARE ALSO A PROBLEM, USUALLY INVOLVING THE PRIVATE, NOT-FOR-PROFIT AGENCY FOR IT IS ADVANTAGEOUS TO THEM TO HAVE VIRTUALLY ALL THEIR COSTS OF DOING BUSINESS, AND THEN SOME, RETURNED THROUGH MEDICARE'S REIMBURSEMENT OF TOTAL COSTS. WHAT IT MEANS FOR THE PATIENTS IS THAT THEY WILL RECEIVE SERVICES UNTIL THEY EXHAUST THEIR MEDICARE BENEFIT, AND THEN THEY ARE DROPPED. MOREOVER, WITH THREE DIFFERENT FUNDING PROGRAMS FOR HOME CARE, IT HAS BEEN POSSIBLE FOR SOME UNSCRUPULOUS SWITCHING. THUS THE HEALTH CARE FINANCING ADMINISTRATION WILL PUBLISH A NOTICE OF LIMITS ON HOME HEALTH CARE COSTS. COMMON COST ALLOCATION AND PROCEDURES ARE BEING DEVELOPED UNDER SECTION 19 OF THE FRAUD AND ABUSE ACT. FINALLY, THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE IS PROVIDING A PACKAGE OF STANDARDS, PROVIDER TYPES, BENEFIT PACKAGES, AND ELIGIBILITY CRITERIA. (MHP)