August 3, 2012

Texas leads the nation in suspect Medicare billings for home health care

Fishy billing practices at 1,000 of Texas' home healthcare agencies have the nation's top federal healthcare watchdog urging a freeze of enrolling new providers here.

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Fishy billing practices at 1,000 of Texas' home healthcare agencies have the nation's top federal healthcare watchdog urging a freeze of enrolling new providers here.

Texas was the nation's largest source of suspect claims, producing nearly 40 percent of all questionable billings. And of Texas' 2,212 home health agencies, 45 percent filed questionable claims for Medicare dollars -- five times the national average, according to a report by the inspector general for the U.S. Department of Health and Human Services.

Double-dipping was one problem, with the federal government receiving bills for stays at nursing homes and hospital at the same time claims were filed for home health services. The billing raised red flags because patients couldn't be in two places at once.

Another oversight: Death. Medicare paid $208,000 for 50 deceased patients, including about $11,000 in services for someone who passed away in 1995.

The Centers for Medicare and Medicaid Services, known as CMS, administers funds and monitors home health agencies. It responded to the report by noting that overlapping hospital and home health stays as well as payments for the deceased cost $5 million, a minuscule percentage - less than .03 percent - of claims.

Marilyn Tavenner, acting CMS administrator, agreed the agency should consider imposing a temporary moratorium here and in Florida and will evaluate "effectively and thoughtfully," which potential provider types and geographic areas it might target. Tavenner wrote in a letter that CMS would also evaluate the impact to access to care for patients, which could "be triggered by a moratorium on new HHA enrollments ..."

Rachel Hammon, executive director of the Texas Association for Home Care & Hospice said it is important to note the inspector general's findings were based on claims data rather than medical documentation.

Those "do not determine whether the services billed were inappropriate or fraudulent rather than aberrant," she said in a statement.

The report recommends that Texas and Florida, which also has high numbers of questionable billings, should be placed under a moratorium of enrollment of providers. As a percent of questionable claims nationwide, Florida was a distant second at 25 percent, but its rate of questionable billing was nearly six times the national average, highest in the country.

Hammon said that any "potential moratorium should be temporary and last only until regulators fully implement the already available tools to combat fraud that do not disrupt patient service."

Pattern of problems

Texas has been a hotbed for home health fraud. The inspector general's report made note of the February arrest of a Dallas doctor and others accused of a $375 million home health agency fraud that touched dozens of providers. Investigators said the fraud would be the single largest home health agency scam in U.S. history.

The doctor has pleaded not guilty to charges including healthcare fraud. The government suspended 78 home health agencies associated with him "based on credible allegations of fraud against them," according the U.S. Attorney's Office. It isn't clear where the home health agencies are located.

In its report, the inspector general said it would refer inappropriate claims it found to CMS. However, federal authorities appear to rarely crack down on owners and employees of home health agencies.

About 100 people associated with home health agencies are barred from receiving federal healthcare dollars for violations such as fraud, according to Star-Telegram analysis of federal exclusions data back from August to 1979. Of those, about 30 were listed as owner/operators. So far this year, no one connected to home health has been excluded from federal funding.

CMS has other remedies, though, such as requiring providers to submit to payment reviews, suspend payments and other actions.

Seeking restitution

Criminal courts have stopped some home health providers, though restitution is often hard to recover.

In 2004, a Fort Worth woman and her husband, owners of a home healthcare business, were convicted of defrauding Medicare. But seven years passed before the government recovered $2.87 million hidden in an account on an island in the English Channel established by a trust created on a Pacific island.

Recent investigations and other studies have found that home health services are vulnerable to fraud, waste, and abuse.

This year, the inspector general found that 22 percent of home health claims were submitted in error, resulting in $432 million in improper payments.

Texas is a magnet for home health agencies. It pays $8,339 per patient, the most in the country. In 2010, Texas served 368,722 patients and received $3.1 billion in payments, the most in the nation, according to CMS data. That year, Medicare paid $19.5 billion to agencies serving 3.4 million people, most of them alive.

Darren Barbee, 817-390-7126

Twitter: @DarrenBarbee

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