We must be wary of growth, as it usually brings fraud right along with it. The modern medical practice serves as a perfect laboratory for fraud. Something new growing in the healthcare petri dish is physician house calls.
Before transportation was practical and available to everyone, doctors traveled to see patients, treating them in their homes rather than offices or clinics. As transportation became available to everyone, doctors soon shifted their practice to offices in order to maximize their ability to treat as many patients as possible. In 1930, house calls accounted for about 40 percent of doctor-patient visits nationwide, but by 1980 they bottomed out around one percent. Slowly, those numbers are starting come back. Medicare spending on doctors who make house calls rose to $236 million in 2012 — a 40% increase since 2006.
Medicare spending on doctors who make house calls rose to $236 million in 2012 — a 40% increase since 2006.
While house calls can reduce the likelihood of new or repeat hospital stays and drive down overall Medicare costs, they also expose vulnerabilities for fraud which I call the gray (as in hair) area. Traditionally covered under Medicare, seniors are the most likely candidates or users of in-home services. Seniors are also easily misled or absent minded in checking their explanartion of benefits (EOBs). A lack of oversight and supervision coupled with a susceptible population is a recipe for fraud.
A doctor must certify that a patient is homebound to get into the home healthcare program, which has given rise to a new niche practice: mobile doctors who certify patients for referral to home healthcare. These visits are billed based on the complexity of the case and time spent with the patient. However, oversight is an issue in this setting. In many cases, there is no one monitoring the providers to determine, for example, if evaluation and treatment time lasted five minutes or an hour.
Thankfully, enforcement and oversight is not far behind. In last year's working plan, OIG identified home healthcare as an area of increased of interest. In recent years, more doctors have been indicted in fraud cases centered on these home visits. Among the recent indictments are a collection of classic health fraud schemes, such as:
- Billing for treatment which wasn't necessary, didn't occur, or was performed poorly
- Billing for the most expensive type of home visit, though providing less
- Receiving kickbacks for referring healthy patients to home health agencies
- Submitting claims for home care when beneficiaries were hospitalized or even dead
It would be unfair to lump all house calls into the fraud bucket. There are certainly benefits to this practice and a great majority of physicians are legitimate caregivers. Home visits allow providers to visually verify the conditions of the home in order to develop a better plan of care. How a patient’s living conditions impact their recovery and well-being is an important part of the puzzle.
We should all expect growth in this area. Data from the American Academy of Home Care Medicine suggests four million Medicare patients had a medical necessity for house calls in 2012, but only 15% received even one visit. If you have information about potential home health fraud, do not hesitate to contact our office.