Medicare may have overpaid $2 billion for fake house calls, HHS investigator says

Obamacare is fighting an uphill battle to cut down on Medicare fraud, but a new report details a $2 billion blow to those efforts from medical personnel who are possibly scamming the government by lying about home visits of patients.

The president’s Affordable Care Act (ACA) requires physicians to conduct a face-to-face visit first to ensure patients who request home care actually are too ill to travel to a hospital or doctor’s office. And it requires the doctors to provide specific proof that they are in fact making the house call.

But Medicare has long been battling doctors who bill the government for home visits they never made, and a report released by the Health and Human Services Inspector General said that despite the new regulations, the practice is continuing.

“The Medicare program doesn’t really have a system in place to ensure the providers are meeting the face-to-face requirement,” said Danielle Fletcher, a program analyst in the IG’s Office of Evaluation and Inspections. “Medicare has found a lot of fraud in home health. The expectation is that the face-to-face visit helps prevent that fraud by ensuring the physicians see and assess the patient, and document that visit and assessment.”

Investigators said that roughly one-third of all house calls were lacking proof that the visit ever actually took place, usually missing a description of what exactly happened during the visit or a signature from a supervisor.

And the IG is worried that $2 billion could have been mispaid because of it.

Officials at the Center for Medicare and Medicaid Services said they are working on a number of fixes, including possibly creating a standardized form for all doctors to fill out that would provide much of the information officials would need to prove the visit actually took place.

“We will consider whether or not a form will help resolve the issues identified,” a response from the agency said. “However, we note that the use of a standardized form would eliminate some of the current flexibilities that providers are afforded.”

Officials also said they are looking at ways to improve direct communication with the doctors making the visits, thereby increasing Medicare’s oversight.

Of the face-to-face visits the IG looked at, about 10 percent had no documentation or proof whatsoever, totaling $605 million. And while investigator’s questioning of the complete $2 billion doesn’t mean all visits were fraudulent, it’s been a common problem Medicare has been repeatedly trying to stop.

Last year, they placed a moratorium on new home health-care providers in Miami and Chicago — two cities where scams were running rampant. In fact, the number of doctors claiming to provide home visits in Miami was 2,000 percent higher than in other Florida areas, CMS said.

The IG said that some physicians never provided a clear reason why patients were unable to visit a doctor’s office themselves. Some of the most common reasons cited were that the patient was “weak” or that it would be a “taxing effort to leave home.”

But such vague descriptions didn’t provide federal officials with any information on whether payment for home visits was warranted, Ms. Fletcher said.

“The phrase ‘taxing effort to leave home’ is included in medicare’s definition of ‘homebound,’ so it doesn’t really tell us anything specific about the patient’s condition,” she said.

Medicare is currently debating whether to expand the face-to-face visit program as a requirement before patients receive durable medical equipment (DME).

Covering a wide range of home medical equipment, from oxygen devices to prosthetics, DME’s have long been plagued by high amounts of waste and several times have won the Golden Hammer, The Washington Times’ distinction for fiscal abuse with taxpayer funds.

CMS is hoping that requiring a face-to-face home visit before approval will cut down on waste and stop patients from getting equipment that they don’t need.