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Keeping watch on those who hold the public trust and money

Watchdog warns home health program vulnerable to fraud

This could be a lesson on how not to catch cheaters: Let those under scrutiny decide who investigators talk with. 

That’s a problem with the way home health agencies are scrutinized in the government’s effort to prevent fraud, waste and abuse in the Medicare program, a federal watchdog warns in a new report. 

Home health agencies are required to undergo surveys at least every three years, where some patients’ records are checked and some patients may be interviewed at their homes. The goal is to make sure that the patients are getting care they need and that the government isn’t being billed for services patients didn’t need or didn’t get. 

But the home health agencies themselves supply the list of patients to be reviewed, says the report by the Office of the Inspector General for the U.S. Department of Health & Human Services. 

And the inspector general found that some lists that agencies supplied were missing patients on Medicare. One roster the OIG examined was missing more than 150 patients – nearly 90 percent of the total. 

This is a significant vulnerability that could be exploited by unscrupulous agencies, the OIG says. Home health has long been recognized as susceptible to waste, fraud and abuse. 

Back in 1995, one notable fraud case involved a Georgia-based home health agency investigated at the request of a congressman, resulting in a seven-year prison sentence for the CEO after he was convicted on dozens of counts of fraud. 

The problem hasn’t ceased. From 2011 to 2015, OIG investigations involving home health resulted in more than 350 criminal and civil actions. 

In a related issue, the OIG says, one agency may have discharged patients to avoid surveyor scrutiny. 

Medicare only pays for home-based care if it is requested by a physician as medically necessary for home-bound patients. The care can include nursing services, physical therapy, and a home health aide. 

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About the Author

Lois Norder is Senior Editor for Investigations in the newsroom at The Atlanta Journal-Constitution.