MEDICARE: FRAUD HIGH IN HOME CARE SYSTEM

      "Nearly 40% of the home health care services provided to
 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).  
      MORE OVERSIGHT?

 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).