Home Healthcare Fraud

Home healthcare fraud involves the submission of false or inflated Medicare claims by home health agencies seeking payment for services that are unnecessary, improperly documented, or never provided. Exploiting the system’s reliance on physician certification and patient eligibility, these schemes cost taxpayers billions each year. Whistleblowers play a vital role in exposing such misconduct and helping the government recover funds lost to fraud and abuse.

According to a 2015 report released by the HHS Office of the Inspector General, Medicare paid out $18.4 billion in reimbursements to home health agencies (HHAs) in that year alone; of this sum, a whopping $10 billion was estimated to have been remunerated for fraudulently submitted claims. Home health programs are widely recognized for their susceptibility to fraud and abuse, and the losses claimed contribute largely to the approximated $60 billion bilked from Medicare each year.

In order to qualify for home healthcare services under Medicare statutes, a patient must be certified by a physician to have a “homebound” status, indicating that they are medically unable to leave the confines of their home. Additionally, they must require physical therapy, speech-language pathology, and/or intermittent skilled nursing services to be eligible to receive care in an HHA facility.

Approximately one in four home health agencies employ questionable billing practices to misrepresent the nature of their patients in efforts to receive undue reimbursement for services that are either not provided or not medically necessary. Common fraudulent billing practices include:

• Falsifying physician care plans to make it appear as though a patient is homebound
• Providing kickbacks to recruiters, discharge planners, and physicians in exchange for patient referrals
• Submitting claims that overlap with inpatient hospital or skilled nursing facility (SNF) stays
• Claiming that services were provided to federal standards, when they were either not medically necessary or not provided whatsoever
• Upcoding; the practice of overstating a patient’s medical needs in order to receive higher reimbursement rates
• Submitting claims that allege care was provided after a patient’s death

Between 2011 and 2015, the investigations stemming from such fraudulent claims have resulted in the discovery of more than 350 cases of home healthcare fraud and the subsequent recovery of over $975 million. Whistleblowers have the unique opportunity to report these exploitations and file cases on behalf of the government, under the qui tam provisions of the False Claims Act. In return, whistleblowers are entitled to a percentage of the recovered funds as a reward.