MEDICARE: FRAUD HIGH IN HOME CARE SYSTEM
"Nearly 40% of the home health care services provided toThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
frail elderly Americans under the Medicare program are
unjustified, either because the service is not necessary, the
person is not covered or the agency administering the care is not
sanctioned to do so," Washington Post reports. Federal
investigators studied four states and found that "the
inappropriate payments drained away more than a third of the $6.7
billion spent in the states investigated during the 15-month
study period." The results were reported by the inspector
general's office of the Department of Health and Human Services
and the General Accounting Office yesterday at a Senate Special
Committee on Aging hearing.
IN THE COMFORT OF YOUR OWN HOME
Under the Medicare home health program, home-bound seniors
can "receive nursing care, therapy, and other assistance in such
basic activities as bathing and getting out of bed. That care is
supposed to be approved by a doctor and reviewed every 62 days."
However, the audits found that this oversight often does not
happen. According to the analysis of patient care in California,
New York, Texas and Illinois, 21% of services provided "were not
deemed reasonable and necessary," 13% of patients were not
homebound, six percent of services were provided without doctor
approval, and one percent of services did not have the necessary
supporting documentation (Havemann, 7/29).
Los Angeles Times reports that although home care spending
"jumped from $2.6 billion in 1989 to nearly $18 billion this
year, Congress has cut back the money allocated for audits and
fraud investigations." Sixty percent of home health claims were
reviewed in 1989, compared with only three percent today.
Although Congress has been focusing on waste in the Medicare
system, Times reports that the government "must weigh the amount
of improper charges that could be prevented or recovered against
the cost of increased enforcement." There is currently
legislation pending in Congress that would "change the payment
system for home health care to control costs." Under the
legislation, agencies "would receive a fixed amount for each case
rather than reimbursement for assorted services" (Rosenblatt,
7/29). ABC's Judd reported, "Not only is the government behind
the curve in monitoring the industry, it's hard to see how it can
catch up when 100 new providers go into business every month"
("World News Tonight," 7/28). Health Care Financing
Administration Administrator Bruce Vladeck said, "The basic rules
of the game have to change. It's not just that we need more
umpires, we have to change the rules of how we define the
responsibilities of a home care agency, how we define the
benefit, and how we pay for it" (Post, 7/29).