Ignorance is no excuse: Education can keep you out of Medicare trouble
What your staff doesn’t know will hurt you
One, two, three strikes you’re out! At least that’s what the U.S. Congress is telling home care agencies these days as federal lawmakers push for even tougher anti-fraud and abuse measures for Medicare.
The Medicare reform proposal currently under consideration appears to have the president’s blessing as well. As part of the balanced budget agreement, the measure would reduce Medicare spending by $115 billion to keep the program solvent and institute further penalties for home care agencies found guilty of defrauding Medicare.
The House Ways and Means Committee approved Medicare reform legislation June 9, following the proposal put forth by U.S. Rep. Bill Thomas, chairman of the Health Subcommittee on Ways and Means. His legislation permanently excludes from Medicare and Medicaid any provider convicted of three health care-related crimes.
The House Commerce Committee and the U.S. Senate were working on their versions of Medicare reform legislation as Homecare Education Management went to press. Legislators say they hope to have a bill on the president’s desk by late summer.
But before you respond that there’s no way your agency would defraud the government, consider these examples of fraud provided by experts contacted by HEM:
• Perhaps your agency has one or two field nurses who routinely forget to keep track of their mileage until the end of the day. Then they have to use rough estimates.
• Maybe a home care aide was running late and missed all but a few minutes of an appointment with a patient. Then, to avoid a reprimand, the aide convinced the patient to sign records showing that the aide was there the entire time.
• Suppose one of your staff therapists routinely sees a patient at a church they both attend. Although the therapist knows that patient is considered homebound by Medicare, the therapist chooses not to say anything about it to the agency’s management.
Investigations are likely
Small, unimportant infractions?
Not according to the federal government. These practices could land your agency in hot water if Medicare fraud investigators come knocking. And the federal government has decided to spotlight the home care industry’s practices because of its rapid growth and a perception that there’s widespread fraud.
So it’s more likely now than ever before that your agency will be audited or investigated by federal officials.
A single complaint to the government’s fraud hotline (which received more than 13,000 complaints in the past two years), and voila the home care provider could receive a call from a Medicare auditor. Or it might be worse.
"Sometimes, there are FBI agents who show up at your door and lock the door, and they say no one can leave. Then they take all the documents away in a truck," says Elizabeth Hogue, an attorney from Burtonsville, MD. Hogue specializes in health law and represents home care providers across the country.
Hogue and other experts say the most effective way to prevent these kinds of problems is through a comprehensive educational program.
"Education of the whole staff is a key component to every single fraud, abuse, and compliance plan," Hogue says. (See tips to teaching staff how to avoid fraud and abuse, p. 104.)
Union Hospital Home Health of Dover, OH, has been educating staff on fraud and abuse for nearly two years. And the hospital-based agency has been working on a compliance program.
"We discuss it in orientation with new staff members, and we give every employee the Medicare handbook," says Deborah Albaugh, RN, BSN, home health director of the agency, which serves five counties in eastern-central Ohio.
Albaugh says the agency teaches staff the five crucial keys to whether a patient can receive Medicare coverage: homebound status, physician order, skilled care, reasonable services, and medically necessary.
Medicare will pay for home health services if the patient is "confined to the home except for infrequent or short absences or trips for medical care," according to the U.S. Department of Health and Human Services’ Office of Inspector General.1
Also, skilled care refers specifically to physical therapy, speech-language pathology, or intermittent skilled nursing care.
"We question nurses about the homebound status of patients and ask them, Why are we in there? Why is it reasonable and necessary, and why is it skilled? We just hammer it in until it’s as natural to them as breathing," Albaugh says.
Here’s a situation that could become a Medicare gray area, Albaugh suggests: Suppose a patient comes home from the hospital and is on medication. The physician doesn’t believe the patient is stable and orders lab work on the patient’s blood each week. So for three weeks the home care nurse draws blood, and each time, the lab results show the patient is stable.
"Is it reasonable to keep on doing this once a week? Probably not," Albaugh says, adding that the agency should call the physician and suggest the nurse draw the blood once a month.
This example also points out how education for physicians is important, Albaugh adds. In the above case, the patient could decide to switch home care agencies to continue to receive the weekly visit.
But this could place the physician at risk for investigation by Medicare, experts say. Union Hospital has notified area physicians that they need to make sure they sign care plans for patients who meet Medicare guidelines. One way they can check on this is to make sure a particular patient hasn’t been turned down for care by another home care agency based on the patient’s disqualification for Medicare services, Albaugh says.
Union Hospital has sent physicians the Medicare handbook and meets with them in a monthly meeting that soon could include an inservice on Medicare fraud and abuse.
Teach staff 2 major types of Medicare fraud
When educating either staff or physicians, it’s important to focus on the two major types of Medicare fraud and abuse, the experts say. These are as follows:
• False claims: This type includes billing for services that weren’t provided or billing for services when the beneficiaries didn’t meet the requirements for the benefit, or billing for inappropriate or unnecessary care, Hogue explains.
Here’s another case that could trigger a Medicare investigation into a false claim: "Let’s say, for example, a patient’s plan of care goals had not been met," she adds. "But the agency’s staff members established a relationship with the patient, and they didn’t want to discontinue seeing the patient."
Another type would be if an agency had a nurse visit a patient each day for six months, although the standard practice would be to end the daily nursing care after one week, says Karen Wade, RN, MS, director of home care services for St. Margaret Mercy Home Care of Hammond, IN. The hospital-based, full-service nonprofit agency has two sites in Indiana and one in Illinois.
Also, red flags go up when Medicare is billed for equipment that the typical patient with that problem wouldn’t need, Wade adds. This could include a charge for a walker or wheelchair when the patient only has a sprained ankle and can get by without those items.
A Medicare audit could nail an agency on even the smallest of details, Hogue and Wade emphasize.
"Technically, it’s fraud and abuse even if they write down they traveled 10 miles, and it’s really only eight miles," Wade says. "If I put down 10 miles, and everyday I pad my mileage by the two miles, then I’m collecting 31 cents a mile from the hospital, and that could be a lot of money."
• Kickbacks or illegal remuneration: This includes any valuable incentives an agency might give a physician for referrals, and it could include gifts the agency’s staff might receive from a medical equipment company.
But it also might include cases in which an equipment company says they will give discounts in the rental cost based on the number of referrals the agency makes, Wade says. (See How the feds define "kickbacks," p. 107.)
"You have to pay a fair market value within the industry standard," she adds.
However, the agency can go with a lowest bidder in a contract for a specific amount of equipment.
On the other hand, home care providers cannot offer physicians an expense-paid trip to a home care conference in Hawaii in exchange for referrals. Nor can they provide a physician with free rent in an office building in exchange for referrals. Both of these examples would be seen as kickbacks.
Medicare officials also might look carefully at how a home care agency uses its home care coordinators and liaisons in hospitals, Hogue says.
"The agencies need to be very sure that the use of those coordinators and liaisons does not amount to providing free discharge planning services to hospitals in exchange for referrals," Hogue explains.
"They need to be sure they have a written referral before they begin the process of coordination of home care services, and if they’d just do that, they’d be a lot further along than a lot of them are right now," she adds.
This type of scrutiny has come as a shock to many home care professionals.
When Wade first began to teach St. Margaret Mercy Home Care’s staff about fraud and abuse, they were "mortified," she recalls.
"The big key is the staff doesn’t comprehend how important their role is and how serious an error in documentation can be," Wade adds.
Before the inservice, some employees resented the close scrutiny and thought it was excessive, she says. "We assured them that this is for their own protection."
Hogue calls the federal government’s intense focus on home care a "completely new world."
"We used to look at ourselves and say that we are good people who do good things; we’re helping people, and we have good motivations and good intentions," Hogue says.
"What [the government’s] saying is that’s not good enough. We have to be certain we’re going beyond good intentions to provide the necessary services," she adds.
Reference
1. Office of Inspector General, Department of Health and Human Services. Special Fraud Alerts: Home Health Fraud, and Fraud and Abuse in the Provision of Medical Supplies to Nursing Facilities. Fed Reg 1995; 60, 154; 40847-40851.
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