This article is part of the HHCN+ Membership
There is a villainous icon in the home health care industry.
But according to William A. Dombe, president of the National Association of Home Care & Hospice (NAHC), there is a difference between a provider who makes an error in billing or delivering quality of care and one who knowingly engages in fraud.
“Blatant and deliberate fraud is the issue of greatest concern,” he told Home Health Care News. “Bad actors are those who get into home health care with the intent of stealing money from Medicare, Medicaid, etc. Their goal is not to provide care, as opposed to those who make mistakes but whose goal is to provide quality care that meets standards.”
Simply put, bad actors are the types of providers that regulators want to drive out of home health care and that industry peers want to avoid being associated with.
A history of cheaters in space
Home health care has gone through phases in terms of the prevalence of bad actors in the industry.
Dombi noted that bad actors in home care were rampant in the 1990s, especially in certain parts of the country.
“South Florida was an area that got a lot of attention,” he said, “to the point where the Department of Justice actually formed an interagency hit squad to go after home health care, and everyone from the Federal Trade Commission to the U.S. Post Office got involved and brought in all sorts of resources. There were a lot of indictments, a lot of convictions and guilty pleas, and significant prison time and fines.”
Over the next two decades, the presence of bad actors in home health care declined, but these providers never completely disappeared from the sector.
One structure that became popular in the early 2000s was setting up home health agencies whose sole purpose was to sell inventory rather than provide care.
“This isn’t the kind of roll-up that some investors are looking at,” Dombi said, “It’s just people trying to stock shelves, like a convenience store, to sell stuff. We’re seeing a little bit of a resurgence of it in home health, but the same concept is also being introduced to hospice in the (Los Angeles) area. When you look at these (agencies), you’re seeing some of the same types of risk identifiers that we’ve seen over the past few years.”
Hospice has become a target for fraud in the California area, but home health care may not be completely immune.
“In California, we’ve heard anecdotes about patients being switched between[home health and hospice]facilities in order to get reimbursed on both sides of the payment system,” Katie Barnett, director of home care and hospice operations and policy at LeadingAge, told HHCN. “I think that kind of fraud is more prevalent than we know because no one is looking closely at the data. To be fair to researchers, information on CMS’s agency surveys hasn’t been updated since the second quarter of 2022.”
Impact on the industry
In theory, it may seem easy for providers operating in good faith to stay on the right track, but the actions of bad actors have implications for the entire industry.
Often, these measures result in broadly applicable regulations that create administrative burdens for honest providers.
“I would like to see targeted enforcement,” Dombi said. “They have the ability to target these providers, whether that be special rules for new service providers or just saying, ‘We’ve decided to do an audit, we’ve chosen to investigate you,’ because there’s nothing stopping them from doing an audit or an investigation if suspicions arise or whatever.”
The presence of bad actors can also tarnish the reputation of home health care overall.
“In the ’90s, I was in a cab in Boston and the driver asked me, ‘What are you doing?'” Dombi says. “I explained, and he said, ‘That’s a healthcare fraud area.’ When a Boston cab driver brings it up, it obviously damages your reputation. It may not be a big deal when you’re talking to a Boston cab driver, but when that reputation makes it to the Legislature, and we’ve had to deal with it many times, they’re not going to believe anything the community puts forward.”
Dombi noted that this presents a stumbling block for industry advocates as they try to inform Congress about issues of access to health care.
“They think, ‘Oh, there’s a fraud problem over there, these people can’t be trusted,'” he says. “There’s nothing worse than not being trusted because of the actions of the bad guys in the barrel.”
Perhaps one of the biggest impacts bad actors have had on the home health sector is the implementation of the Patient-Driven Grouping Model (PDGM), which replaced the previous Prospective Payment System (PPS).
“There were a lot of unscrupulous operators who were prioritizing profits over patient care and were gaming the system to increase their profits,” Barnett said. “That was the catalyst for us to move to a different system where we weren’t paid by the number of treatments.”
Good actors don’t let bad actors drive the narrative, despite the harmful impact they have.
“I think there’s a lot of good people trying to step up and speak up about the problems in the system and talk more about the good work that’s being done in home health care,” Barnett said.
After all, the presence of bad actors contributes to increased cooperation among good actors.
“I think this bill has brought the home health community together and put in place a high level of collaboration to show both Congress and CMS that we can be an effective and reliable partner,” Dombi said. “Similarly, the same thing is happening on the hospice side. It’s helped bring providers closer together.”
