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Identify Potential Fraud for Home Health Trends in E/M, Outliers & POS

  • by Cindy Gallee, JD, RHIA, CHC
  • Feb 27, 2015, 11:33 AM

Investigators have long considered Home Health claims to be rife with the potential for fraud. The daily news illustrates this point as fraud convictions of Home Health operators appear regularly. Last week, an owner of a Miami Home Health company pleaded guilty to a $13 million fraud, perpetuated by kickbacks and bribes to patients and medical providers for referrals and prescriptions that were used to fraudulently bill Medicare.1 Data indicating fraud in home health claims has important implications because Medicare has issued moratoria on the opening of any new home health agency in six geographical areas in the country deemed particularly problematic for fraud.The Affordable Care Act addresses the issue of fraud in Home Health claims by requiring a face-to-face visit between a physician and patient as a condition of payment for home health services. The Office of Inspector General (OIG) has recently audited Home Health claims and determined there was a 32 percent failure rate in documenting this face-to-face visit in the study – obtained from Evaluation and Management claims filed by providers. The OIG translated this rate to be a Medicare overpayment of $2 billion for claims reviewed in a one-year period.2

Payers can take away several useful conclusions from this study:

  • Reviewing provider Evaluation and Management trends is an important tool in demonstrating provider compliance with federal and payer rules, and can indicate areas of potential fraud.
  • Identifying outliers such as high volume in certain geographic areas can be useful for further investigation.
  • High volume in the place of service (POS) 12 (Home) for professional claims, or type of bill 32X or 34X (Home Health Services) for institutional claims can identify where investigation may be needed.
  • Evaluation and Management visits within the required time frame of a home health visit can establish whether home health claims adhere to the face-to-face visit rule.

Context4 Healthcare, Inc. has a solution for evaluating trends in Evaluation and Management visits with reports that can show outliers on any user-defined variable. Though outliers are not always indicative of fraud, they can give a useful place to start for investigation. Context's FWAHawk™starts with real-time claims analysis during the FirstPass™ claim review, then provides options for reporting and analytics to help identify potential fraud before the claim is paid or repriced.

Read more on this topic: Detect Unusual Patterns in Service & Patient Volume in All Specialties

 1See for the Department of Justice press release dated February 17, 2015.

2See for the Office of Inspector General April 9, 2014 reported entitled “Limited Compliance with Medicare’s Home Health Face to Face Documentation Requirements.

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