A new comprehensive study is shining a light on potential factors that have led to home health billing fraud over the years.
Among other findings, researchers at Dartmouth’s Geisel School of Medicine concluded that home health agencies that share patients across multiple agencies, and those that had high rates of expenditures across hospital referral regions (HRRs), were more likely to commit fraud than others.
The study’s authors defined fraud as either knowingly billing for services with no benefit for — or harm to — patients, or billing for services not provided.
One of the main indicators the study authors followed was spending in certain regions far outpacing Medicare spending in others.
“We first found a remarkable increase in home health care activity between 2002 and 2009 in many regions targeted by the DOJ,” the authors wrote. “The average billing per Medicare enrollee in McAllen, Texas and Miami increased by $2,127 and $2,422 compared to just an average $289 increase in other HRRs not targeted by the DOJ.”
There was substantial growth in Medicare spending for home health care services from 2002 to 2009: $14.9 billion in 2002 to $33.7 billion in 2009.
However, the massive increases were highly concentrated in just a few regions of the U.S.
For example, in the Miami region, home health expenditures rose 302% from $802 in 2002 to $3,229 in 2009, per Medicare enrollee.
In comparison, home health billing in Los Angeles saw a significantly smaller increase from $782 in 2002 to $861 in 2009, a 10% jump.
“These billing increases cannot be explained by changing health needs, nor can they be explained by the substitution of inpatient care for home health care,” the authors wrote. “Instead, they appear largely the consequence of widespread fraudulent behavior which in turn attracted specific DOJ strike-force offices located in areas with rapid increases in fraudulent behavior.”
Matt Wolfe, office managing shareholder at the law firm Baker Donelson, wrote in an email to Home Health Care News that although the study does not measure actual fraud, it does provide some interesting insights into how purported “fraud” occurs in home health.
“Observers should be careful not to generalize too much from the study,” Wolfe wrote. “Studies like these should help policymakers and regulators better finetune their enforcement toolbox to address and stymie bad behavior while not catching innocent providers in their dragnets. More of this kind of analysis is necessary to protect the home health benefit — by rooting out bad behavior, evolving oversight and ensuring access to those patients in need.”
The study’s authors also were able to pin down characteristics where fraud would be likely. Those included “rapid” increases in rates over time, substantial growth in the number of agencies in a certain area and whether a region would attract a DOJ anti-fraud office.
The study found a correlation in the areas where home health spending skyrocketed and where the DOJ eventually set up those satellite anti-fraud offices.
“Home health agencies sharing patients with multiple high-billing agencies were more likely to experience higher expenditures in the following year,” the authors wrote.
The tool researchers built — called the BMIX index — could also be used as a predictive model moving forward, although with limitations.
“While we established that the BMIX index is theoretically consistent with a model of diffusion and is predictive of subsequent growth in home health expenditures, we cannot prove causality in these nor in the peer-effect analyses,” the authors wrote. “The BMIX index is not likely to be capturing unmeasured health effects, but patient sharing patterns could be symptomatic of past or current fraudulent activity which in turn lays the groundwork for future fraudulent behavior.”
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