Dr. Mehmet Oz, administrator of the U.S. Centers for Medicare and Medicaid Services (CMS), and other CMS officials zeroed in on home health and hospice fraud at recent conferences in Nevada and California.
Oz, CMS Chief Operating Officer Kimberly Brandt, and Medicare Director Chris Klomp visited Nathan Adelson Hospice in Nevada and then held a roundtable listening session with Leading Age, the National Home Care Alliance, the National Partnership for Healthcare and Hospice Innovation (NPHI), the California Hospice and Palliative Care Association, and approximately 15 hospice and home health providers.
The conversation focused on strengthening program integrity and eliminating bad actors in this area.
“[CMS]has been hearing about[the fraud]from a variety of sources and decided it was time to go and see what was going on on the ground,” Molly Gurian, Leading Age's vice president of policy and government, told Hospice News, a sister publication of Home Health Care News.
Home health care has been identified as a “prime target” for Medicare fraud, leading to increased action among home health agencies to combat suspicious activity.
The Medicare Payment Advisory Commission (MedPAC) recently voted to recommend a 7% reduction in Medicare home health cuts, but identified “concerns about program integrity” among home health agencies, particularly those in Los Angeles County, California, an area that has become a model for fraud in the home health sector.
Home health care industry stakeholders are calling on CMS to root out home health fraud and avoid using fraudulent or questionable data in the methodology for determining home health Medicare payments.
Hillary Loeffler, vice president of policy and regulation at the Alliance, told Hospice News that Oz's conversations with industry officials focused specifically on questions about physicians.
“It's very difficult to make these plans succeed without physician involvement, and he was very interested in what needs to happen today to move physician ethics and schooling in line with these plans,” Loeffler said. “He was very focused on the types of kickback arrangements that were in place. He was also very interested in the scope of the issue.”
According to Tom Koutsoumpas, founder and CEO of NPHI, other important topics discussed included:
What healthcare providers are seeing in the field How fraudulent and abusive behavior manifests in practice How current oversight approaches impact high-performing healthcare providers What information does CMS need to make informed policy and enforcement decisions Better target audits and oversight for conduct that indicates fraud or abuse (e.g., high discharge rates, failure to provide all four levels of care) Avoid unnecessary burdens on high-quality nonprofit healthcare providers Leveraging Provider Experience to Inform More Effective Enforcement Strategies How aspects of the current hospice benefit structure unintentionally invite fraud are potential reforms that CMS could consider to strengthen program integrity while preserving access to quality care, including eligibility, payment, and quality outcomes.
Home health industry representatives and CMS leaders discussed how fraud distorts payment rates.
“(CMS) is doing these calculations to figure out if they're overpaying home health agencies based on the (patient-driven grouping model) that they put in place, and the way they do that is by re-pricing claims. In Los Angeles County. home health care issues have really started to skyrocket in the last few years. So if you're trying to compare the current amount of claims to what would have been paid in a pre-2020 scenario, that's a mountain of money,” Loeffler said. What we think is that there are enough claims patterns coming out of Los Angeles that are influencing the calculations, including claims from Los Angeles County, which skews the numbers. ”
Oz also took a “ride-along” tour of areas in Los Angeles County that are rife with fraudulent providers who often operate from the same address, Kutsonpas told Hospice News. After the meeting, Oz held a press conference and vowed to crack down on fraud. A few days later, a group of members of Congress sent a letter to CMS requesting further action against these scams.
“We applaud the administration for taking decisive action to combat fraud, waste and abuse in hospice care and for recognizing that strong program integrity is essential to ensuring patients and families receive the highest standards of care during the most vulnerable times in their lives,” Kutsompas said in a statement emailed to Hospice News. “By giving people a firsthand look at care from trusted nonprofit providers, CMS leaders are sending a clear message that protecting quality and access is a priority.”
Prior to the event, LeadingAge and the Alliance sent a letter to CMS with recommendations on how to combat fraudulent operators.
