President hones in on home care fraud
No direct implications for hospices
The federal drumbeat on waste, fraud, and abuse in health care picked up the tempo in mid-September with the announcement of a new national initiative to combat fraud in the home care industry. Although this new initiative is targeted specifically at Medicare-certified home health agencies and does not directly include hospices, there may be some fallout for hospice’s image with a public that only reads headlines about health care fraud. The government’s initiative slaps a moratorium on new home health agency certifications for at least the next six months, which will slow any new efforts by hospices to become dually certified in order to care for patients who don’t fit Medicare hospice criteria.
No fly-by-night providers’
On Sept. 15 in a speech to the Service Employees International Union in Washington, DC, President Clinton announced the moratorium and other new measures to crack down on fraud and abuse for the $18-billion home care industry. These come on top of a handful of anti-fraud measures contained in the budget reconciliation bill signed by the President in August, and in last year’s Health Insurance Portability and Accountability Act. Home care has also been targeted by recent highly critical reports issued by the General Accounting Office and the Office of Inspector General.
"Today I’m declaring an immediate moratorium on the admission of new home health agencies to Medicare. And during this moratorium, we’ll develop tough new regulations to ensure that no fly-by-night providers enter or remain in the Medicare program," Clinton said. "Second, I’m requiring all home health agencies to re-enroll every three years so that they, too, will abide by these standards. Third, we will double the number of audits of home health agencies currently involved in the Medicare program."
Other anti-fraud provisions targeting home care include:
- As part of the re-enrollment process, agencies will have to submit to an independent audit of their records and practices.
- New home health agencies will be required to serve a minimum number of patients prior to seeking certification to demonstrate their expertise.
- Agencies will be required to post a $50,000 surety bond before they are certified.
- Convicted health care felons will be barred from receiving Medicare payments ever again, as will their families.
- Structural reforms will be implemented to control the growth of home health care.
The same day as the President’s speech, Health and Human Services (HHS) Secretary Donna E. Shalala denounced "the fraud that has become so prevalent in the home health industry. . . There is an urgent need to make fundamental changes in the way this program does business with home health providers." The temporary moratorium had been recommended by HHS Inspector General June Gibbs Brown to facilitate implementing new home care program safeguards included in the budget bill. "The actions taken today are another strong step in this administration’s efforts to fight waste, fraud, and abuse in the home health industry," Brown said.
"What the President has done is to underscore that the government will not tolerate fraud and abuse," says John J. Mahoney, president of the National Hospice Organization in Arlington, VA. In terms of their impact on hospice, "I don’t think the public draws clear boundaries between categories of providers. The moratorium itself does not extend to hospice, but if any hospices were looking to get into home care," they will now have to wait for the necessary certification, he says. "State hospice organizations should also have a heads up on unscrupulous operators who would have liked to get into home care and now may be looking somewhere else," like hospice.
The Washington, DC-based National Association of Home Care (NAHC), which has announced its own position of "zero tolerance for fraud and abuse and unnecessary utilization," issued a statement questioning whether the President’s message "will wrongly suggest that fraud and abuse are epidemic rather than isolated and episodic" in home care.
Other observers point out that much of the government’s scrutiny has targeted the subjective issues of homebound status and skilled need in the home care regulations not actual fraud.
Adds Diane M. Jones, MSW, ACSW, executive director of NAHC’s affiliated Hospice Association of America, "Eventually, we’ll come to our senses and realize: My God, what are we doing to these elderly people in need?’"
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