A few weeks ago, more than 240 healthcare workers—including doctors, nurses and other licensed professionals—were arrested for allegedly participating in Medicare fraud schemes to the tune of $712 million. The arrests were part of a coordinated operation in 17 cities by Medicare Fraud Strike Force teams, which include personnel from the FBI, the Department of Health and Human Services, the Department of Justice and local law enforcement. Since 2007, Strike Force teams in nine cities have charged more than 2,300 defendants who collectively falsely billed Medicare more than $7 billion. These most recent arrests constitute the largest-ever healthcare fraud takedown in terms of both arrests and dollars lost.
Peter Carr, a DOJ spokesman told Modern Healthcare that around half of the DOJ's current healthcare fraud caseload involves allegations involving home healthcare agencies. William Dombi, a vice president at the National Association for Home Care and Hospice, estimates he's seeing a new indictment or conviction on an almost weekly basis. Although the charges are based on a variety of fraud schemes, many involve submitting Medicare claims for treatments that were medically unnecessary or were not even actually provided. In other cases, Medicare beneficiaries and other co-conspirators are accepting cash kickbacks for supplying beneficiary information so providers can submit fraudulent bills to Medicare.
An honest mistake?
Some say it's easy for home health agencies to inadvertently commit Medicare fraud because services that are deemed medically necessary by a medical professional may not be allowable under Medicare. But Dombi told Modern Healthcare that many fraud cases aren't based on subjective determinations of medical necessity; they're based on whether agencies billed for services that were never provided or were clearly unnecessary. "These are pretty black and white," he said.
Another area of contention is kickbacks paid to recruiters to bring in more Medicare patients, which is not allowable under Medicare. In some cases, agencies are unknowingly breaking the law by offering bonuses to employees for referrals. But more often than not, those who are accepting kickbacks know exactly what they're doing.
Crackdown under the ACA
The new authorities granted to HHS and the Centers for Medicare & Medicaid Services under the Affordable Care Act have been instrumental in clamping down on fraudulent healthcare claims. In FY 2013, CMS announced its first use of a temporary moratoria authority granted by the ACA. The action stopped enrollment of new home health agencies or ambulance companies in three fraud hot spots around the country, allowing CMS and its law enforcement partners to remove bad actors from the program while blocking provider entry or re-entry into these already over-supplied markets. "We've cracked down on tens of thousands of healthcare providers suspected of Medicare fraud," said former HHS secretary Kathleen Sebelius, who was still in office at the time. "New enrollment screening techniques are proving effective in preventing high-risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results—all of which are adding to savings for the Medicare Trust Fund."
Federal scrutiny of home health agencies is not likely to end anytime soon, as government agencies plan to continue their fight to eliminate healthcare fraud. "We will not stop here," said HHS Secretary Sylvia Mathews Burwell. "We will work tirelessly to prevent these programs from becoming targets and fight fraud wherever we find it."