Home Health Medicare Fraud and Its Prevention - Research Paper Example

of Lecturer] Law Home Health Medicare Fraud and its Prevention Introduction In the last couple of years, Medicare has been quite upbeat and practical in its efforts create public awareness about Medicare fraud, which is considered a national problem given that fraud costs the program millions of dollars annually. That the Medicare program uses a multi-pronged and multi-disciplinary approaches and sources to help with the detection and prevention of Medicare fraud little has been done to achieved a meaningful success (NAHC, 1). To achieve some level of success in arresting the menace of Medicare fraud, stakeholders, especially professional health care providers should first understand the meaning and scope of Medicare fraud. Generally, Medicare fraud refers to any act of willfully and knowingly billing medical claims in an attempt to swindle, dupe or deceive the Medicare program for money. The Government Accountability Office (GAO) considers Medicare and Medic aid as high risks programs given their vulnerability to abuse, wastage, fraud and mismanagement. According to GAO, Medicare fraud results in losses of up to $60 billion annually (Department of Health and Human Services 6). Although this statistics may not be accurate, the level of fraud, abuse and wastage in Medicare is massive. In fact, it is believed that even the Center for Medicare and Medicaid Services (CMS) do not have a clear idea on the extent of Medicare fraud and wastage. Medicare fraud is not only an issue for the CMS but also for the Congress, which has really had interest in Medicare in the last two decades. Despite the attention and interest directed at Medicare fraud and wastage, little has changed with reference to curbing the fraudulent and wasteful practices (NAHC, 1). In fact, there are indications that Medicare fraud is fast overtaking drug trade as a profitable criminal business. The main reasons for this state of affairs are the apparently low penalties for offenders and lack of violence in Medicare fraud crimes. Although the government constantly places additional measures to screen Medicare suppliers and providers and to stop payments shrouded in fraud or alleged to be fraudulent, there is still a lot to be done to reverses the fraud trends among providers (Department of Health and Human Services 31). There are repercussions for engaging in any acts of Medicare fraud and those found guilty stand to be excluded from participating in Medicare programs. Moreover, an offender could face heavy fines and imprisonment. The main areas in which Medicare fraud are reported are could be billing for durable medical equipment, billing for physicians services and billing for nursing homes, hospitals and hospice institutions (NAHC, 6). In spite of the many federal regulations and laws on Medicare, fraud continues to grow and spread in the program. Regrettably, while this strictness and increased regulation keeps away honest and genuine providers, dishonest and unscrupulous business have ventured into the program and are ripping off the Medicare program and the taxpayer of their money. This paper explores the existent and the extent of billing fraud and wastage by HHAs and gives recommendations on the interventions or strategies by which this wastage and fraud could be reduced or eliminated altogether. Cases and Statistics of Medicare Fraud Medicare fraud and wastage by Home Health Agencies (HHAs) reached the alarming levels of about half a million dollars in 2013. This statistics was obtained from a government hotline, which reportedly received 1,116 Medicare-related tip-offs in the last financial year. This statistics concurs with the general public belief that Medicare is being wasted and ripped off to the tune of hundreds of thousands of dollars annually (NAHC, 5). Currently, the Department of Health and Human Services is investigating 275 cases, out of which 34 cases have been submitted to the federal director of public prosecutions while about 12 people have been convicted in the recent past (Department of Health and Human Services 15). According to the Department of Health and Human Services, the total amount ripped off the 12 convicted fraudsters stands at an estimated $474,000. Evidently, that ten of the convicts were members of the public, one a medical practice owner, and the other a clinic employee shows that Medicare fraud and wastage is not a preserve for home health agencies and other health care practitioners (Department of Health and Human Services 12). In particular, doctors have been at the forefront of Medicare wastage and fraud. For instance, a report entitled ‘The Use of Medicare and the Pharmaceutical Benefits Scheme (PBS) for 2012-13,’ shows19 cases of doctors being ordered to repay a total of $1.09m. In addition, in the 2012-2013 periods, 14 doctors received reprimands whereas four were suspended or disqualified from accessing Medicare and the PBS altogether. Among the techniques by which fraudulent and inappropriate or questionable billings are tracked include the 80/20 rule, which focuses on inappropriate practices. According to the 80/20 rule, it is suspicious for a doctor to see 80% of more of patients on 20 or more days in a year. In addition, it was revealed in the report that there are days in which 500 or more attendance claims were made. Similarly, there are cases in which more than 200 claims are made, raising fraud questions. Although it may be considered that the rate of fraud is slightly small or negligible compared to the hundreds of millions of Medicare transactions conducted annually, the practices that result in fraud and wastage in Medicare are not acceptable (Torio & Andrews, 44). In a report entitled ‘Inappropriate and Questionable Billing by Medicare Home Health Agencies,’ in 2012, the Inspector General of the Department of Health and Human Services, Daniel R. Levinson reported that home health services are prone to wastage, abuse and fraud. In fact, in the report, it was indicated that quite a huge portion of the $19.5 billion paid to home health agencies was either wasted or fraudulently obtained (Department of Health and Human Services 3). These conclusions were arrived at following a study that critically analysed recorded data from inpatient healthcare facilities, home health agencies and claims from skilled nursing facilities. The purpose of this scrutiny was to identify and quantify inappropriate and fraudulent home health payments made by the Medicare. From the measures of questionable payments used in the study, the Department of Health and Human Services identified many home health agencies that billed exorbitantly high amounts. Although there could have been other genuine reasons for these extremely high billings, fraud was suspected to be a core reason as well (Department of Health and Human Services 8). The other objective achieved by this study was the location of the home health agencies (HHAs) involved in the questionable and inappropriate billings. Three core avenues for high and inappropriate billing by HHAs were identified. These avenues were claims overlapping with inpatient stays, claims overlapping with stays at skilled nursing facilities and bills for services ostensibly offered after beneficiaries’ death (Department of Health and Human Services 21). Among the states in which HHAs with unusually high billings were spotted are Michigan, California, Florida and Texas. However, these findings do not imply that other states do not experience or report cases of inappropriate and questionable billing from HHAs. Based on its findings, the Department of Health and Human Service listed several recommendations. First, the Centers for Medicare and Medicaid Services (CMS) were urged to apply edits in claim processing in addition to making the existing edits more effective. These edits, it was recommended, ought to place a lot of emphasis on the three main types of errors identified as causing billing frauds by HHAs. The need for a thorough monitoring of HHA s was emphasised just as the importance of reducing the 10% cap on the outlier payments for HHAs annually. The need to impose temporary moratorium on new HHA enrolment for the affected states was emphasised. Finally, the Department of Health and Human Services called for appropriate legal and professional action against HHAs found with inappropriate and questionable billing (Torio & Andrews, 44). Although the government continues to enact laws and regulations to curtail Medicare fraud in the home health sector more fraudulent HHAs are entering the sector while genuine and honest home health providers are kept away by these stringent rules, laws and regulations. Worse still, the regulations and laws have not effectively addressed the inappropriate and questionable billing by HHAs. Moreover, services to patients have become increasingly poor despite the huge billing by HHAs. If media reports are anything to go by, Illinois also has its fair share of cases of Medicare billing wastages and misappropriation by HHAs. An example of the many cases of Medicare fraud in Chicago is the Illinois hospice executive and owner who was charged with federal health care fraud for allegedly falsely elevating level of patients’ care. The hospice owner, Seth Gillman from Lincolnwood, allegedly took part in a large scheme to receive higher Medicare and Medicaid payments by deceitfully elevating the level of hospice care for patients. Notably, many of these patients resided at nursing homes owned by the same executive across Chicago. It was also alleged that the level of hospice care given to patients at Gillman’s facilities by far exceeded what is considered medically necessary besides the claims exceeding what was actually provided. For instance, there were cases in which patients were admitted for periods longer than the expectancy period of six months. Moreover, some of the patients on whom claims were made did not suffer from terminal illnesses. In a criminal complaint filed in U.S. District Court on 24th January 2014, Gillman, 46, was charged with one count each of health care fraud and obstructing a federal audit. Gillman co-owns Passages Hospice, LLC, based in west suburban Lisle. He also has interests in Asta Healthcare Company, Inc. and Asta Care Center nursing homes, which have branches in Colfax, Elgin, Ford County, Bloomington, Pontiac, Rockford, and Toluca, in Illinois. In the charges, Gillman was accused of training and causing to be trained Passages nurses so that they would identify and search for signs that would qualify a hospice patient for general inpatient care (GIP). This practice translated into higher payments per day, compared to routine care. Although Passages did not own inpatient facility, they deployed nurses to visit hospice patients in nursing homes and private residences. In addition, it was argued before the court that Gillman was aware that some of his facilities’ patients were placed on GIP without a medical director’s approval. It was claimed that between January 2006 and late 2011, Passages submitted claims were for about 4,769 patients to Medicare and/or Medicaid against whom a payment of approximately $95 million from Medicare and $30 million from Medicaid were made. In the affidavit before the court, it was revealed that federal and state agents conducted interviews among patients, their families as well as with past and serving workers of Passages. In fact, among these employees of Passages were those who reported the alleged fraudulent billing and market practices relating to Medicare and law enforcement even before the federal agents interviewed or contacted them. Signs of Medicare fraud were also noted in emails, patient files and documents obtained after search warrants and subpoenas were issued in 2013. The other sources of fraud suspicion were claims data from Medicare. According to the claims data from Medicare, about 22% of Passages’ patients between 2006 and late 2011 had received more than six months of hospice care. Out of these patients, 28 received more than 1000 days of hospice care within this timeframe. These claims data contrasted the data obtained from the National Hospice and Palliative Care Organization, which reported that a mere 11.8 percent of all hospice patients in were on hospice care for longer than six months in 2009. The second case illustrating the extent to which Medicare is being ripped off involves as Chicago psychiatrist Dr. Michael J. Reinstein, who allegedly submitted at least 190,000 false claims to Medicare and Medicaid. In the lawsuit facing the suspect, it was alleged that illegal kickbacks were received for prescription to antipsychotic medication for nursing home patients. The kickbacks were received from pharmaceutical organisations. The defendant was also charged with the offense of fraudulently submitting not less than 50,000 claims to Medicare and Medicaid, falsely stating that pharmacologic management was offered to these patients. According to Gary Shapiro, Acting United States Attorney for the Northern District of Illinois, this was perhaps the biggest civil case of alleged prescription medication fraud against an individual ever in Chicago. The two cases are just examples of the many cases of Medicare fraud that bedevil the Medicare program. The huge sums of money lost under these schemes point to the necessity of designing, developing and implementing interventions to prevent Medicare fraud and wastage. Prevention of Medicare Fraud and Wastage To prevent, detect and eliminate fraud and wastage in the Medicare program, interventions must be initiated and first implemented at the individual level (Torio & Andrews, 25). That is, it is the role of every person to protect oneself from Medicare-related errors, fraud, and abuse. To protect oneself and effectively fight health care fraud and abuse, it is of the essence to protect personal information. Thus, an individual can make a difference and save Medicare and Medicaid from losing billions of dollars annually. An individual can contribute to the fight against Medicare fraud by protecting the health care benefits, not giving Medicare, Medicaid or Social Security numbers to strangers and being aware of con people who call or pay visits (Department of Health and Human Services 9). Individuals should also be quick and alert enough to detect potential errors, fraud, and abuse. Of greatest importance is for individual patients to closely and keenly watch their medical records to detect any anomalies. That is, the Medicare Summary Notices and Part D Explanation of Benefits for mistakes should be reviewed. In addition, patients should regularly access their Medicare account 24 hours a day at the website www.MyMedicare.gov. It is also important to compare the Medicare Summary Notices and Part D Explanation of Benefits to personal health care. The role of the billing statement in fighting Medicare fraud is cannot be overstated. The key signs that an individual should look for in the billing statement to detect any fraud are charges for services or medications not given, double- or triple-billing for the same service and services not ordered by the physician (Torio & Andrews, 36). It is equally important that one asks questions on any aspect of the billing statement not properly understood. Questions should also be asked whenever a patient he or she did not receive a service indicated as given and when there is a feeling of an unnecessary treatment conducted (Department of Health and Human Services 13). It would be an exercise in futility to observe these anomalies, abuses, errors and fraud without reporting it to authorities. Fraudsters have formed schemes by which Medicare is ripped off. It is vital that members of the public are aware of these schemes so that the right alarm is raised whenever such a scheme is detected. One of these schemes is the billing for Durable Medical Equipment (DME). These DMEs are equipment that are needed for patients’ medical and physical conditions and include wheelchairs, mobility scooters, and hospital beds. In some cases, a home health agency bills Medicare for equipment that was never received or used by a patient (Torio & Andrews, 28). In fact, the mobility scooters are considered the most notorious fraud scheme used to abuse the Medicare program. The second Medicare fraud scheme is called ‘Services Never Performed.’ In this scheme a home health agency bills Medicare for diagnoses, tests, treatment and procedures that were never performed. These fake tests and treatments are then included among those genuinely received by a patient. In addition, some health care providers have been observed to forge diagnosis codes, to enable them add unnecessary tests or services (Department of Health and Human Services 23). The third Medicare fraud scheme is called the Up-coding Charges, which entails the misrepresentation of the levels of services offered and procedures performed with the main objective of increasing charges and receiving higher reimbursement rates. Second, up-coding may refer to a situation in which a service performed by a provider is not included among those funded by Medicare, which a provider replaces it with a covered treatment or procedure and bills Medicare (NAHC, 10). The fourth fraud scheme against which patients should be on the lookout is referred to as ‘Unbundling Charges,’ which affects all inclusive services. Unbundling refers to the billing for procedures separately while they should be billed under one charge. For an illustration a HHA may conduct one bilateral screening mammogram but decide to bill Medicare for two unilateral screening mammograms (Torio & Andrews, 29). Besides being aware of these fraud schemes that are used by HHAs, it is vital that the public is aware of the indicators of Medicare fraud so that whenever an indicator is detected, the right authorities are contacted. Conclusion According to the Government Accountability Office, Medicare is one of the most high-risk programs in the USA in modern times. This statement is true despite the myriad laws and regulation designed to streamline the actions of home health agencies (HHAs). However, this tight regulation has only driven away honest providers, replacing them with fraudulent providers who not only waste Medicare resources but also abuse and fraud the program of its resources. Inappropriate and questionable billing is the main way in which dishonest providers deceive Medicare. Under billing, the main schemes by which Medicare is swindled are unbundling charges, up-coding, Durable Medical Equipment (DME) and Services Never Performed. The prevention and control of Medicare fraud depends on the extent to which members of the public and personnel from the Medicare regulatory authorities are aware of these schemes. In addition, the consequences of committing acts associated with these schemes should be severe to deter the would-be fraudsters from engaging in such activities. It is also important that all stakeholders address all the issues regarding Medicare programs’ abuse and fraud, considering that the program is financed by public funds. To further expand the government financing of healthcare programs, especially those of Medicare, Medicaid and the national health insurance, a more effective control of fraud and abuse is mandatory. Moreover, the use of the appropriate mechanisms to reduce medical care cost and to improve the quality of life should not be neglected. Interdisciplinary approach to the control of fraud and abuse would also be effective in addressing the medico-legal and public policy issues pertaining to fraud and abuse in Medicare. With the current advances in technology, it is recommended that new techniques be applied in the fight against Medicare fraud and abuse. For an illustration, the Health Care Fraud Prevention and Enforcement Action Team propose the use of advanced data analysis technology, which is among the new and effective weapons in the fight against fraud. On a rather positive note, it has been noted that Medicare fraud controllers are making progress in the identification of irregular and suspicious patterns in claim submissions. One approach by which this success is being achieved is via collaboration and sharing of data among fraud control agencies. In addition, the controller teams are focusing more efforts on cities and states identified as hot spots for Medicare fraud and wastage. Works Cited Department of Health and Human Services. “Avoiding Medicare Fraud and Abuse; A Roadmap for Physicians,” 2012. Retrieved on March 26, 2014 from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf The National Association for Home Care and Hospice (NAHC). “Home Care Medicaid Fraud Developments in a Half Dozen States,” 2014. Retrieved on March 26, 2014 from http://www.nahc.org/NAHCReport/nr140303_2/ Torio, C. M., and Andrews, R. M. “National Inpatient Hospital Costs: The Most Expensive Conditions by Payer,” 2011. Agency for Healthcare Research and Quality, Rockville, MD. Read More