Avoiding Home Health Fraud

When I was a federal prosecutor, one of the big problems I tackled was home health fraud. 

Home health fraud was so widespread in Chicago that the federal government tried some big measures that had limited success - a moratorium on new home health agencies and a requirement that every home health claim be reviewed before being paid.  The federal government also devoted a lot of resources into the investigation and prosecution of home health fraud, but this also had limited success.  Criminal prosecutions can be effective, but they require a lot of resources and have limited success when fraud is rampant.

I investigated and prosecuted many home health fraud cases, and I was consulted on many others.  I also studied fraud extensively;  I once ran data analysis on every home health claim billed in Illinois over several years to detect patterns and trends.

Through all this, I realized one crucial problem that contributed significantly to home health fraud.

Medicare relied on doctors to be gatekeepers for home health services, but Medicare did little if anything to make sure that doctors actually knew the requirements that they were supposed to be enforcing.

In other words, Medicare expected doctors to order home health services only for patients who were “confined to home” or homebound, but Medicare did not really do anything to make sure that doctors knew what Medicare’s definition of “confined to the home” was.

If you’re a doctor who works in home health services, you can find the definition in Medicare Benefit Policy Manual, chapter 7, section 30.  But you probably have never read the Medicare Benefit Policy Manual, so here’s the definition:

• Criteria 1

  • The patient must either: -

    • Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence

      • OR

    • Have a condition such that leaving his or her home is medically contraindicated.

• Criteria 2

  • There must exist a normal inability to leave home;

    • AND –

  • Leaving home must require a considerable and taxing effort

This is a strict definition, not one that should be used for every elderly patient. 

Here are some actual, specific examples that Medicare gives of people who would be considered “confined to the home”:

• A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant weakness and pain because of the surgery and; therefore, their actions may be restricted by their physician or allowed practitioner to certain specified and limited activities (such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.).

• A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk.

• A patient who is blind or senile and requires the assistance of another person in leaving their place of residence.

• A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence.

• A patient in the late stages of ALS or neurodegenerative disabilities …

• A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity.

• A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.

Medicare warns:  "The aged person who does not often travel from home because of frailty and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless they meet one of the above conditions.”

If you were given or taught a different definition, you may have authorized home health services that should not have been billed to Medicare.  This is real and serious.

Moreover, be careful if anyone asks you to discharge a patient and then to re-admit the patient for home health services soon afterwards and without any significant change in medical condition.  This is a common tactic that people use to bill Medicare for unnecessary home health services.  If you have been asked to do this, you may have authorized home health services that should not have been billed to Medicare. And anyone who asks you to do this is likely doing other things that are illegal, such as claiming patients are sicker than they actually are in order to increase the amounts Medicare will pay.

Each time you order home health services, a home health agency likely will bill Medicare for services that may cost thousands of dollars for each episode. This can add up to huge amounts that the government may try to hold you responsible for.

If you believe that you may have improperly authorized home health services, you should consider taking corrective action to protect yourself from criminal investigation by the federal government.  You should contact a lawyer who specializes in health care fraud cases and who can represent your interests, not the interests of your employer or a home health agency that may be committing fraud. 

If you need help contacting a lawyer, you can contact me or a bar association in your area.  You can also consider calling the Federal Defender in your area, and they may be able to provide you with help.