OIG Reports on Common Characteristics in Home Health Fraud Cases.

Date posted: July 6, 2016

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a study analyzing Medicare claims associated with home health fraud cases.  The OIG analyzed data from calendar years (CYs) 2014 and 2015 to assess the prevalence and distribution of characteristics common to home health agencies (HHAs).  The OIG examined: (1) statistical outlier HHAs and physicians whose data varied drastically compared to their peers; and (2) geographic “hotspot” locations containing a high volume of statistical outliers.

The OIG found that outliers saw high percentages of the following characteristics:

  1. Episodes where beneficiaries had no recent visits with supervising physicians;
  2. Episodes that did not follow a hospital or nursing home stay;
  3. Episodes with a primary diagnosis of diabetes or hypertension;
  4. Beneficiaries with claims from multiple HHAs; and
  5. Beneficiaries with multiple home health readmissions in short timeframes.

Further, the OIG made the following findings:

  • In CY 2015, Medicare reimbursed outlier HHAs roughly $273 million for over 100,000 home health episodes;
  • Over 500 HHAs (5 percent) and 4,500 physicians (1 percent) were statistical outliers on 2 or more characteristics commonly found in OIG home health fraud cases;
  • Nearly 500 HHAs and over 16,500 physicians had an unusually high percentage of episodes where the home health beneficiary had no recent visits with the supervising physician;
  • Nearly 800 HHAs and 4,000 physicians had an unusually high percentage of beneficiaries with multiple home health readmissions in a short timeframe;
  • In CYs 2014 and 2015, 6 beneficiaries received services from 10 or more HHAs;
  • Geographic hotspots for characteristics prevalent in home health fraud cases existed in 27 locations across 12 states; and
  • In CY 2015, 35 percent of all home health episodes and 37 percent of all home health spending occurred in geographic hotspots.

The OIG concluded that home health continues to warrant careful attention from HHS agencies and law enforcement due to a high potential for fraud, waste, and abuse.

The OIG report is available at:

http://oig.hhs.gov/oei/reports/oei-05-16-00031.pdf.

Department of Health and Human Services Office of Inspector General.  “Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases.”  OEI-05-16-00031.  21 Jun. 2016.

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