Recently, I heard a story about a mid-sized house call practice – a solid operation with tenured staff and a good reputation. In the wake of a competitor’s shutdown after an FBI raid to investigate potential Medicare fraud, the owner of this practice gathered staff together for a reassuring meeting. In this meeting, it was stressed that their practice was nothing like the one that had been shut down. They had proper checks and balances in place. Every patient was accurately assessed and documented. They had nothing to worry about. Any audit would show they were an excellent organization that followed all the rules.
Less than one year later, this owner was shocked when the FBI came knocking, leveling the same charges their competitor had faced a mere 11 months prior. The same press releases went out, the same Assistant U.S. Attorney was leading the charge, and the practice was (temporarily) out of business.
Unfortunately, this story isn’t unique. A look at healthcare news sources over the last two years will show that, practically every month, a new story emerges of the Medicare Fraud Strike Force raiding an allegedly fraudulent house call practice. It may seem that these cases are a few bad apples in a sea of well-meaning house call groups – but each has carried the same charges: ordering medically unnecessary services, improper documentation, and violation of the Stark Act. That is not to say there are not bad guys out there – because there certainly are. But every house call practice struggles with the gray area of defining “homebound” and how to properly code each visit.
And it’s not just house call practices. Earlier this year, there was national media coverage when Duke University Hospital came under scrutiny for allegedly overbilling Medicare to the tune of $626,133. This was just one month after Duke Health System (which the hospital is a part of) was accused of receiving $1 million in Medicare overpayments. Duke agreed to reimburse the government for the $1.6 million slight … but you don’t see anyone accusing Duke – a U.S. News and World Report #1 ranked hospital – of being a fraudulent enterprise. And if the murky Medicare regulations can trip up this world-class health system, they can trip up anyone.
If you look at the trends, it appears that the Medicare Fraud Strike Force, established in 2007 and expanded in 2009, has recently begun targeting house call practices. If you are a house call practice in the United States, you should assume that you are (or, more specifically, your Medicare billing is) being watched. You may think you’re not doing anything wrong, but neither did the CEOs I referenced above – until their warrants were served.
As advocates of the home-based primary care industry and the fragile patient population we serve, it’s critical that we work together and encourage our support system, including the American Academy of Home Care Medicine, to more fully engage the Office of Inspector General (OIG) on the dangers of targeting house call practices in this way. Very often, while the investigation is going on, the bank accounts of the practice are frozen, which is a death sentence to an industry that survives on razor-thin profit margins. Even when the OIG and U.S. Attorney find no actual merit to the accusations, it’s usually too late for the practice – a valuable community service was shuttered, dozens or hundreds went to the already over-taxed unemployment lines, and at-risk patients went without needed care and medications.
Going forward, this is the single greatest threat to the house call industry. It’s time for us, as a community, to engage the OIG in a dialogue of how to make changes to these investigations so that good house call companies – and their patients – don’t get hurt in the fight to stop the true fraudulent players.