by bvernia | January 12th, 2010
In a report published on December 7, the Office of Inspector General of HHS reported that outlier payments for home health agency services in Miami-Dade County, Florida. The report reveals both opportunities and impediments in fighting Medicare fraud.
Medicare provides supplemental payments – known as outlier payments – to home health care providers who provide services to unusually high-cost beneficiaries. As part of the joint DOJ/HHS Health Care Fraud Prevention and Enforcement Action Team (HEAT) operating in South Florida, OIG-HHS launched a review of outlier payments in Miami and Dade County, Florida.
The results are striking:
- Miami-Dade County outlier payments totaled more than the result of country combined
- Diabetes-related outlier payments in Miami-Dade County were more than eight times the national average
- Over 85% of providers nationally who received outlier payments greater than $100,000 per beneficiary were in Miami-Dade County
There is currently no limit on outlier payments to individual home health care providers, but the total for all payments cannot exceed 5% of projected costs. Last year, CMS proposed a rule that would cap outlier payments to individual providers at 10%, and OIG-HHS recommended continuing this effort. The OIG also recommended reviewing home health providers exhibiting “aberrant” outlier payment patterns, and limiting enrollment of home health agencies having “characteristics associated with fraudulent activity,” such as sharing the same practice location, or selling or transferring agency ownership within three years of enrollment.
What the OIG-HHS report fails to do, however, is recognize the need to enlist the public and Medicare beneficiaries in preventing and reporting fraud. The report notes that 23 other counties exhibit similar (but less serious) patterns of aberrant home health outlier payment patterns. Unfortunately, the report fails to name these localities, saying in a footnote that the counties “may be subject to future OIG and HEAT reviews.”
The OIG’s reticence at identifying potential problem counties runs counter to Congress’s desire to increase whistleblower enforcement, and reflects an unrealistic assessment of DOJ and OIG-HHS’s ability to tackle the problem on their own. Although DOJ has recently expanded the Medicare Strike Force model to new cities, it is difficult to believe that the effort can be replicated in a dozen or more new locations soon. An alternative to OIG’s “stovepiping” of this information would be to make it public, thereby enabling qui tam attorneys to seek out whistleblowers in those locations.
