Looking at Medicare claims data for calendar years 2014 and 2015, the Office of the Inspector General has concluded that more than $10 billion of the $18.4 billion paid in CY2015 for healthcare services to Medicare beneficiaries in their homes was "improper."
The use of this word instead of "fraudulent" or "illegal" allows the report to lump together both fraudulent and non-fraudulent activities into one large category, one that includes payments made for services never provided, such as in criminal activities; services actually provided that were later determined to be not medically necessary, such as when clinicians either recertify relatively well patients1 or their documentation is incomplete or sloppy; and services actually provided and medically necessary but that were denied for technicalities, such as missing dates or inadequate wording or signatures on the wrong line on the referring physician's Face-to-Face document.
To illustrate what it has determined to be a common problem, OIG cites the extreme example of Dallas physician Jacques Roy, who coordinated a $375 million fraud scheme and was convicted along with five HHA owners.2 The report makes clear that only claims data was examined to produce the OIG's characteristics common to fraudulent providers, stating, "This data brief is based on analysis of Medicare claims data only; we did not review medical records or other documentation. Moreover, our measures were designed to assess characteristics commonly found in OIG-investigated cases of home health fraud, not to accurately predict or reveal fraudulent activity. Accordingly, our analysis should not be interpreted as demonstrating that specific providers were engaged in fraud."
Two years ago, the OIG issued a report that criticized CMS for failing to train physicians on their expectations for wording on the then new Face-to-Face documentation requirement, and then denying home health claims based on inadequate physician documentation.3
Using a list of five characteristics common to agencies with improper payments (see sidebar), OIG identified "hot spots," or geographical areas where fraud is more common. In order to be named a hot spot, a region had to have
Outliers were identified using a standard statistical tool, which is better described as a direct quote than in summary:
For each measure, we used a standard technique known as the Tukey method to identify HHAs, physicians, and geographic areas that were statistical outliers. Specifically, we identified an HHA, physician, or geographic area as an outlier if its percentage for a given measure was above the 75th percentile plus one and a half times the interquartile range on the distribution of percentages across all HHAs, physicians, and geographic areas, respectively.
Prior to performing the outlier analyses, we excluded HHAs, physicians, and geographic areas with low volumes of home health services. For the first three measures, we excluded HHAs, physicians, and geographic areas with fewer than 10 total episodes of home health care. For the fourth and fifth measures, we excluded HHAs, physicians, and geographic areas with fewer than 10 home health beneficiaries. For all measures, we further excluded geographic areas with fewer than five HHAs.
Twenty-seven problem regions
Using this criteria and the measures described below, OIG named the following cities or counties and their respective surrounding regions as fraud hot spots:
|New York City||Jacksonville, FL||Duval County, TX|
|Philadelphia||The Villages, FL||Brownsville/McAllen/Rio Grande City/Laredo|
|Ogemaw County, MI||Tampa||Provo, UT|
|Ada, OK||Miami / Ft. Lauderdale||Las Vegas|
|Tahlequah, OK||Dallas||Los Angeles|
|Avoyelles Parish, LA||Houston||San Diego|
Measures for Characteristics Commonly Found in OIG Home Health Fraud Cases
We identified five distinct characteristics commonly found in OIG-investigated cases of home health fraud. We then developed measures to assess these characteristics using the NCH datasets. The measures for each characteristic are defined as follows:
1 For an elaboration on the problem we have dubbed "toxic census syndrome" see HCTR, 4/29/15: "Seminar Keynoter Outlines Path Toward Healthcare Reform Success
3 OIG, April 2014. "Limited Compliance with Medicare's Home Health Face-to-Face Documentation Requirements" oig.hhs.gov/oei/reports/OEI-01-12-00390.pdf
©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. email@example.com