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Home health agency 'red flags' for Medicare fraud

Home health care is becoming a more expansive, more vibrant and more important industry every year. And with growth also comes regulation.

After years of deliberations, the Centers for Medicare & Medicaid Services issued a final rule in January that establishes Medicare and Medicaid participation requirements for home health agencies.

The final rule is supposed to take effect July 13, 2017, but the CMS recently proposed delaying the effective date until January 13, 2018 after the industry made clear that adhering to the new requirements will take an extensive amount of time and money.

Requirements of the final rule include:

  • Patients and caregivers must receive written information about services, including medication instructions
  • Licensed clinicians must be in charge of setting up referrals and other services for patients
  • Integrated communication systems must be used to facilitate better collaboration between the agencies and physicians

The final rule states that the requirements "focus on a patient-centered, data-driven, outcome-oriented process that promotes high-quality patient care at all times for all patients."

Once the final rule takes effect, it is likely that the federal government will be carefully monitoring home health agencies for compliance.

What does the government consider home health care fraud red flags?

Last summer, a report by the Office of Inspector General, U.S. Department of Health and Human Services, showed that about 5 percent of home health care agencies had characteristics that often point to home health care fraud.

The five characteristics include:

  1. Episodes of care during which a beneficiary had no recent visits with the supervising doctors.
  2. Episodes of care not preceded by a hospital or nursing home stay.
  3. Episodes of care with a primary diagnosis of diabetes or hypertension.
  4. Beneficiaries with claims from multiple agencies.
  5. Beneficiaries with multiple home health readmission in a short time.

The report also stated that the health care fraud crimes would be investigated and prosecuted more intensely going forward.

What can home health agencies do to stay out of trouble?

The most effective thing a New York home health agency can to do avoid Medicare and Medicaid fraud accusations is to have an effective compliance plan in place when the final rule takes effect -- whether that is in July or January.

An experienced health care attorney can help you avoid red flags that could initiate a fraud investigation into your home health business, which is the last thing that you need.

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