"You're talking about a healthcare service that's more challenging to regulate. People are going into other people's homes, rather than going into a facility," expert says.
The federal government recovered $186 million in 2014 from civil fraud Medicaid cases involving home health care agencies and home health care aides led the list of having the largest number of fraud convictions, in a report released this month by the Office of Inspector General.
The $186 million recovered from home health care agencies represented the largest single amount in the $1.9 billion recovered in total civil judgments and settlements, according to the report.
Attorney John Kelly said he’s not surprised by the amount of recovery dollars in the home health field.
Kelly is a partner in Bass, Berry & Sims LLC, in Washington, D.C., which in March compiled a report on healthcare fraud. Kelly is also former assistant chief for healthcare fraud at the Criminal Division of the Department of Justice.
The government often focuses on certain sectors within an industry, he said. This year CMS developed a pilot program to determine the number of Medicare fraud cases taking place in home health. It’s a $16.6 billion dollar industry, he said.
“What stands out, whether its Medicaid or Medicare, is there is a tremendous amount of scrutiny for home health. There’s billions of dollars at stake, and people are not as closely scrutinized. You’re talking about a healthcare service that’s more challenging to regulate, people are going into other people’s homes, rather than going into a facility.”
Of 1,381 total convictions in fiscal 2014, 413 were for home health care aides, according to the report. This represented 30 percent of all Medicaid Fraud Control Unit criminal convictions and was a small increase over the 26 percent reported in 2013.
Most commonly, the report stated, the aides claimed to have rendered services that were not provided, or they submitted false time sheets for service, sometimes claiming to be working with more than one patient in two different locations.
The government recovered $12 million from convictions of home health care aides and another $546,790 from 21 civil settlements and judgments.
However, these figures pale in comparison to the amount recovered from home health care agencies convicted of fraud. The government received $186 million in civil settlements from 27 home health care agencies, and another $7 million from 48 criminal convictions, according to the report.
In total, the federal government recovered $293 million in 1,381 criminal convictions and $1.9 billion in 889 civil settlements and judgments.
Suppliers of durable medical equipment led the list for the amount recovered for criminal fraud, at $26 million.
The federal government recovered $5.7 billion related to various healthcare fraud in 2014, a $1.9 billion jump over the year before, according to the report by Bass, Berry & Sims in Nashville.