Beware if your home health agency, or the certifying physician for any of your patients, fits a profile the Office of Inspector General (OIG) found in common among OIG-investigated cases of home health fraud.
The OIG released a report identifying 27 clusters of claims from agencies in 12 states with five high percentages of episodes:
For which the beneficiary had no recent visits with the supervising physician;
Not preceded by a hospital or nursing home stay;
With diabetes or hypertension as primary diagnosis;
For beneficiaries with claims from multiple home health agencies;
For > 1 SOC for same beneficiary < 60 days of home health discharge.
The OIG's analysis identified more than 500 home health agencies and more than 4,500 physicians that were outliers in comparison to their peers nationally with respect to multiple characteristics OIG commonly finds when investigating agencies for home health fraud.
"Because these providers differ considerably from their peers with respect to common fraud characteristics—often by substantial margins—they warrant further scrutiny to ensure the integrity of the Medicare home health benefit."
– Office of Inspector General
In 2015, the OIG reports that 37% of all Medicare home health spending was for care provided in the geographic hotspots (See map above from OIG analysis of Medicare claims data, 2016).
The report also warned against assuming that all providers in identified hotspots are committing fraud, and acknowledged that "legitimate explanations" may prove the outlier agencies' statistics. But the OIG plans to investigate and audit outlier home health providers and physicians and may refer some "to CMS for followup as appropriate.