September 25, 2022

Volume XII, Number 268

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Home Health Medicare Fraud: How to Report and Identify Waste and Abuse

Medicare fraud is one of the most common types of fraud in the U.S. today. Home healthcare fraud, a type of Medicare fraud, makes up a significant share of fraudulent activity in America. What makes home health Medicare fraud and abuse difficult to identify and report is the cunning with which doctors and healthcare professionals prey on the sick and elderly.

What makes matters worse is that the beneficiaries who receive home healthcare services are not the only victims. Taxpayers have billions of dollars stolen from them every year in the form of home health Medicare fraud.

Below, we examine the most common types of home health Medicare fraud and give you the tools to identify and report fraud if you witness or suspect it.

What is Home Healthcare Fraud?

Home healthcare fraud is fraud committed by home healthcare companies. It can take many forms but generally involves a healthcare professional intentionally misrepresenting medical claims or records to defraud Medicare out of money. The federal government is hardly the only victim of home healthcare fraud, as it costs American taxpayers billions of dollars every year. It can also lead to poor and unnecessary care of the sick and elderly.

Common Home Healthcare Fraud Schemes

Home healthcare fraud can come in many different forms. Here are some of the most common types of home healthcare fraud:

  • Plan of care fraud: When a Medicare patient has a severe illness or injury and is forced to stay home, they may qualify for home health services under their Medicare plan. In order to qualify, a doctor must certify that they are homebound due to their illness or injury. The entire process needs to be properly documented and submitted. This is called a “plan of care.” If it is not medically necessary for a patient to stay home, but the doctor falsifies documents to that effect, it is an example of plan of care fraud. In some cases, a doctor may offer to meet the patient at their home, citing that it is more convenient for the patient. The doctor will then falsify plan of care documentation. It should be noted that in such a case, the patient has done nothing wrong and is a victim of fraud, not a participant in the fraud.

  • Kickback schemesKickback schemes occur when a doctor or other healthcare professional receives a financial or other type of incentive for referring a Medicare patient to a particular facility or service. One common way this occurs is when home healthcare companies refer patients to assisted living facilities and receive compensation for the referral. If the assisted living facility owns the home healthcare company, and the doctors of one refer patients to the other, this would be an example of kickback fraud.

  • Fraudulent billing: Fraudulent billing occurs when a doctor or healthcare professional bills Medicare for services not rendered. Another way fraudulent billing could occur is if a doctor performs a particular, cheaper service, but bills for another, more expensive procedure or service, known as “upcoding.”

Red Flags for Medicaid Fraud

When fraud occurs, there are numerous red flags to be on the lookout for. These signs of fraud can take place either at home or at a hospital or doctor’s office. Some of the red flags for Medicaid fraud include:

  • Primary Diagnosis Concerns: In healthcare, it is not uncommon for doctors to be dealing with patients who have more than one medical issue at a time. Because of this, when a doctor is faced with multiple diagnoses, they will rank them, assigning one as the primary diagnosis and others as secondary diagnoses. Typically, diagnoses of diabetes or hypertension do not require home healthcare services. When your doctor is committing fraud, they may change the primary diagnosis to something that would merit home health services. If a patient notices unusual activity with their primary diagnosis, it might be a red flag for fraud.

  • Little to no contact with a supervising physician: If a patient is not having regular visits from their physician, they may not be receiving the care they need, or home health services may not be necessary in their situation. If a home healthcare company doesn’t send a doctor to a patient regularly for care, it could be a sign of home health fraud.

  • No services rendered after an in-patient stay: During an in-patient stay, a doctor may order follow-up care to be provided at home. If the home healthcare company never provides that follow-up care, they might still bill for it, which would constitute fraud under the False Claims Act. Be on the lookout for follow-up care that isn’t provided.

  • Multiple readmissions in a short time-frame: One final red flag that home health Medicare fraud is occurring is when a patient has numerous readmissions in a short period of time.

Examples of Healthcare Fraud:

  • Fraudulent Billing and Accounting: Falsifying dates, medical records, or care provided are all examples of fraudulent billing and accounting.

  • Patient Recruitment and Kickbacks: Recruiting patients on behalf of a company or facility in the hopes of receiving a financial kickback from that company or facility is a form of fraud.

  • Fraudulent In-Patient Referrals: Referring patients to in-patient care that is unnecessary or fraudulent in some other way is illegal.

  • Organized Medical Fraud: Healthcare fraud that is organized at multiple levels of an organization or multiple organizations and which pays kickbacks to doctors for falsifying medical records, prescriptions, or certifications constitutes fraud. These coordinated efforts defraud the government of money when they are used to justify unnecessary home healthcare.

What is the Difference between Fraud and Abuse?

In the healthcare industry, fraud is any attempt to intentionally misrepresent some aspect of care in order to receive undue funds from the government. This includes many of the examples listed above, as well as others.

On the other hand, abuse in healthcare is any physical, emotional, or verbal harm committed by a healthcare provider against a patient, but it can also refer to improper or unethical business practices such as kickbacks for referrals or prescriptions, as these practices are inherently harmful to vulnerable patients who trust their doctors to prioritize their medical needs.

The difference between fraud and abuse is that with fraud, the healthcare professional makes a statement or claim to the government, whereas with abuse, they do not.

Hospice Fraud and Abuse

Hospice is a form of home healthcare, as services are provided in the home to a patient who is terminally ill and nearing death or whose mobility is limited by a medical condition. Unfortunately, just like home healthcare companies, companies that provide hospice care can also be guilty of fraud and abuse. The most common ways hospice companies commit fraud or abuse include:

  • Submitting false claims to Medicare for unnecessary care, improper care, or care that was never given

  • Receiving kickbacks for services or referrals

What is the Fraud and Abuse Control Program?

The Health Care Fraud and Abuse Control (HCFAC) Program is a government program directed by the Attorney General and the Health and Human Services Inspector General that coordinates efforts at the federal, state, and local levels to combat fraud.

How to Report Home Healthcare Fraud

If you suspect a home health Medicare company is committing fraud, now is the time to step up and report wrongdoing. However, because of the complex nature of home healthcare fraud, you may want to consider contacting a skilled home health Medicare fraud attorney to help you on your journey.

Reporting fraud may classify you as a whistleblower, which comes with certain protections and provisions under the False Claims Act. To fully leverage all aspects of the law, the assistance of an experienced lawyer may be beneficial.

When to Hire a Whistleblower Lawyer

Witnessing or being the victim of home health fraud or abuse is a serious matter. It can also be a situation in which you are unsure of what to do next. Hiring a lawyer might be the best next step if you can answer yes to any of the following questions:

  • Have you had very little contact with your home healthcare physician?

  • Has your physician tried to refer you to facility that is owned by the home healthcare company?

  • Have you witnessed some other type of fraud or abuse?

Am I Eligible for a Whistleblower Reward?

The False Claims Act (FCA) was enacted by Congress to combat fraud, abuse, and the waste of government funds. It applies to any business that deals with government money or contracts, including companies in disaster relief, agriculture, defense, and healthcare.

Essentially, the FCA encourages ordinary citizens to be on the lookout for fraud and report it when they see it. The way the law does this is by allowing citizens to file lawsuits (known as qui tam lawsuits) on behalf of the government against individuals and companies suspected of fraud.

The law has two key features that apply to those who bring a qui tam case on behalf of the government:

  • Protection: If the person bringing the lawsuit (known as a qui tam relator) is an employee of the company, they are protected from employer retaliation.

  • Financial reward: The person who brings the lawsuit is eligible for 15-30 percent of the money the government recovers.

This means that if you successfully blow the whistle on home health Medicare fraud, you could be eligible for a substantial financial reward.

Report Home Health Medicare Fraud with a Lawyer’s Help

Home health Medicare fraud is a serious problem in the healthcare industry. If you suspect fraud, you can help put a stop to it by working with a dedicated whistleblower attorney. If your case is successful, you may also be eligible for a whistleblower reward. 

© 2022 by Tycko & Zavareei LLPNational Law Review, Volume XII, Number 266
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About this Author

Jonathan K. Tycko leads the Whistleblower Practice Group of Tycko & Zavareei LLP

In recent years, the laws of the United States have undergone a whistleblower revolution. Federal and state governments now offer substantial monetary awards to individuals who come forward with information about fraud on government programs, tax fraud, securities fraud, and fraud involving the banking industry. Whistleblowers also now have important legal protections, designed to prevent retaliation and blacklisting.

The law firm of Tycko & Zavareei LLP works on the cutting edge of this whistleblower revolution, taking on even the most complex and confidential whistleblower...

202-973-0900
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