Home care, hospice fraud trends to watch

Insights from an exclusive interview with Haynes and Boone's Sean McKenna

Monitoring home healthcare and hospice claims is a program integrity priority due to continuing fraud, abuse and general noncompliance involving such benefits. How can payers fight these trends? FierceHealthPayer: Anti-Fraud spoke to Sean McKenna, J.D., to find out.

McKenna (pictured) is a partner in the Dallas office of Haynes and Boone, LLP. He has 15 years of enforcement and healthcare experience, most of which he spent working for the federal government as an assistant U.S. Attorney.

FierceHealthPayer: Anti-Fraud: What trends should insurers watch for in home health-related fraud and abuse? Do the problems differ in Medicare and Medicaid?

Sean McKenna: Home healthcare has been on the law enforcement and payer radar for years. While problems in both programs are similar, the Medicare response has been much more robust since most dollars lost to fraud, abuse and waste are primarily Medicare funds.

Changes under the Affordable Care Act address the perception that home health agencies are riddled with fraud. The ACA requires face-to-face physician certification for the initial visit. Previously, a nurse could call in and a doctor could sign off remotely without actually visiting a patient and completing a complex, detailed narrative. That narrative is now required, and the requirement may extend to recertifications later if there's persistent lack of compliance.

Recently the Office of Inspector General issued a report saying that a sample of about 644 claims showed an error rate of more than 30 percent in failure to document face-to-face encounters or noncompliance with the narrative requirement. These findings seem to indicate poor documentation as opposed to lack of medical necessity or fraud and abuse.