Cleaning up Dodge: The challenge of home care fraud and abuse

Reports of fraud and abuse in home healthcare make this benefit seem like the lawless wild west of government health insurance.  

Cruz Sonia Collado, for example, owner of Nestor Home Health in Miami, was sent to prison Monday for filing more than $6.1 million in fraudulent Medicare claims, WPLG reported. Collado paid kickbacks and bribes to recruiters to round up patients for needless care. She also claimed payment for services never provided.

In Ohio, independent care provider Linda Frame stands accused of billing Medicaid for undocumented home health services, according to The Medina Gazette.

Beatrice Randall in Missouri pleaded guilty to one count of healthcare fraud after filing bogus Medicaid claims for hours worked by a personal home health assistant, the St. Louis Post-Dispatch reported.

And in Illinois, Christopher Spivey admitted to filing similar fraudulent claims for personal assistant services in a Medicaid waiver program, the Department of Justice announced. But here's the cake taker: Spivey was incarcerated in Richland country jail on dates he claimed to have cared for the beneficiary. 

Michigan's Medicaid home help program overpaid $160 million in 29 months, a state audit found earlier this year. More than 3,700 of the program's home help aides were felons convicted for homicide and assault, sex-related crimes, drug-related offenses, fraud, identity theft or other financial crimes. Moreover, the state paid at least $3.3 million in benefits for ineligible recipients.          

Home care benefits serve the vital, supportive purpose of helping the elderly or disabled manage needs of daily living and remain in their homes instead of nursing facilities or other costly care settings. So the benefit is nobly intended to provide quality-of-life advantages and save money. But home care remains riddled with fraud and abuse despite government efforts to saddle this mustang. 

The Centers for Medicare & Medicaid Services, for example, extended its moratoria on new home care provider applications in the fraud-prone cities of Chicago and Miami. And the agency imposed new home care provider application bans in Dallas, Detroit, Houston and Fort Lauderdale, Fla. But the government's long-term failure to remove criminals from its programs has effectively penalized new participants, some of whom may have made a positive difference in the lives of beneficiaries.     

The Affordable Care Act requires doctors to certify that beneficiaries are medically eligible for home care through face-to-face-encounters and completion of a complex, detailed narrative. But an Office of Inspector General audit of about 644 claims showed a more than 30 percent failure rate in documenting compliance with ACA requirements.      

The challenge here is maintaining necessary benefits, connecting eligible beneficiaries with honest providers and screening out the unscrupulous. That's a tall order that begs the question of how.

Do we push for stricter oversight of services through closer monitoring of homebound status? Do we need more prepayment claims review? Should the CMS keep cutting payments for home care? Or do we tackle the problem on the back end with stiffer penalties for those who commit fraud? All these seem like partial, hackneyed solutions to a complex problem payers and the government have grappled with for years.   

We're financing an important benefit that's vulnerable to fraud on a massive scale. We need to change how that benefit is designed or how we manage its inherent fraud and abuse risks, because the status quo is loaded with varmints. Jane (@HealthPayer)

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