CMS drafts new rules to limit home health fraud

The Centers for Medicare & Medicaid Services (CMS) has proposed a rule that would allow the agency to collect baseline data on probable fraud payments in the home health industry and launch a preauthorization pilot project in five states.

The proposed rule, which was quietly released by CMS at the beginning of February, would allow CMS to collect data from a national random sample of nursing homes as part of a probable fraud measurement pilot. CMS would collect information on the service history of various home health agencies, referring providers and the beneficiary in order to establish an baseline estimate of potentially fraudulent payments.

"This demonstration would help assure that payments for home health services are appropriate before the claims are paid, thereby preventing fraud, waste, and abuse," the rule states.

Additionally, CMS intends to launch a prior authorization pilot project in five states--Florida, Texas, Illinois, Michigan, and Massachusetts--with a similar structure as programs aimed at durable medical equipment and power wheelchairs. Both Detroit and Chicago have seen significant home health fraud enforcement within the last year. 

CMS is accepting comments on the proposed rule through April 5. 

Home health fraud has been on the radar of fraud investigators and commercial payers for years, with mid-western states seeing significant enforcement. Recently, federal authorities have come down hard on fraudsters, with some home health agency owners facing as much as 80 months in prison.

To learn more:
- here's the AHA News release