Earlier this year, Amedisys, Inc. paid $150 million to settle seven separate qui tam lawsuits. The whistleblowers in those cases alleged that Amedisys employees submitted false claims to Medicare and maintained improper financial relationships with referring physicians. Among the specific allegations were that Amedisys misrepresented the conditions of its patients on an Outcome and Assessment Information Set (OASIS) forms in order to increase its Medicare billing. Rest assured this is will not be the last settlement in the home healthcare arena.
Home health agencies are part of a high-risk screening by Centers for Medicare and Medicaid (CMS) due to the program vulnerabilities that these healthcare providers pose to the Medicare trust fund. This has been an ongoing problem since as early as 1997 when the Office of the Inspector General (OIG) first reported on home healthcare fraud. At that time, the OIG found that an astonishing 40 percent of home health claims did not meet Medicare reimbursement requirements. A more recent study conducted by the OIG found an unsettling continuance of fraud with some of Medicare’s new home health provider requirements in the Affordable Care Act (ACA).
Some common areas of fraud include:
- Home health agencies use certain elements from the Outcome and Assessment Information Set (OASIS) to determine the payment amount for each 60-day episode of home care for Medicare beneficiaries. These elements in the OASIS contribute to the score that the home health agency uses to assign the patient to a Home Health Resource Group (HHRG). The HHRG reflects the beneficiaries’ condition and need for care. This in turn reflects the amount of reimbursement the home health agency receives from Medicare. Intentionally providing false patient information on the OASIS form to increase a patient’s need for services and thereby increasing payment from Medicare is a false claim. As seen in the Amedisys case, there are many elements that may be exaggerated for increased payment, including needing more assistance with activities of daily living (ADLs); documenting problems with toileting including incontinence; using assistance devices when walking; and documenting unfounded safety risks. Only one person can complete and/or make changes to the OASIS assessment. This has to be a registered nurse (RN), unless rehabilitation therapies are the only services ordered. If therapies are the only services ordered then the OASIS assessment can be completed by the appropriate therapist, such as a physical therapist (PT), an occupational therapist (OC), a speech language pathologist (SLP) or speech therapist (ST). The OASIS assessment must reflect the patient’s current condition.
- Home health services being billed without meeting the appropriate face-to-face Medicare requirements. Such services will be considered non-billable and may be found to be a false claim in an attempt to defraud the government. The face-to-face encounter must occur within a 120-day window, either within 90 days before the start of care (SOC) or up to 30-days after the SOC. Face-to-face documents must include the signature and date of the practitioner performing the evaluation and it must include the clinical findings to support the need for continued home health services.
- A physician-established plan of care is required in order for Medicare to pay for home health services.The physician is required to approve, review, sign and date the plan of care every 60 days. It should include all pertinent diagnoses, functional limitations, frequency of visits and the types of services to be provided. If a Medicare beneficiary does not receive at least one covered home health visit within that 60-day episode, then the plan of care is considered terminated by CMS. If the home health agency plan of care does not meet these guidelines, then the services are considered non-billable and may be found to be a false claim in an attempt to defraud the government.
Other potential areas of fraud include:
- Subcontracting or assigning staff to work in Adult Living Facilities (ALFs), nursing homes, in hospitals as admission/intake coordinators and/or case managers in order to induce or capture home healthcare referrals.
- Home Health Aides (HHAs) providing home services without the appropriate oversight of a registered nurse (RN). Regulations require that a registered nurse must provide oversight and make an onsite visit no less than every 14-days if the patient is receiving skilled care in the home as well as services by an aide. This requirement is not satisfied by a telephone call to the patient and must be performed in the patient’s home.