Preventing Health Care Fraud

History can be the world’s greatest teacher. When we look at the past, we can understand more about the future and how to adapt and change for the better. History has shown us that the more profitable an industry, the more people there will be attempting to cheat the system in an effort to make money quickly. In health care, learning about fraud can assist us in combating the problem. According to the Federal Bureau of Investigation (FBI), health care expenditure is estimated to be about $3.4 trillion in 2014. Tens of billions of dollars in payments are for fraudulent claims. This problem directly impacts taxpayers and depletes resources needed to deliver services to patients who really need the care. What is health care fraud? According to the Centers for Medicare & Medicaid Services (CMS), fraud is defined as “when someone intentionally falsifies information or deceives Medicare.” Common types of health care fraud include medical identity theft, billing for unnecessary services or items, billing for services or items not furnished, upcoding to more complex services and unbundling a single comprehensive code to create individual charges. Fraud can occur in any setting, including hospitals, clinics, pharmacies, medical supplies, critical care facilities and home care. Since 2007, when the Department of Health and Human Services (HHS) established the Medicare Fraud Strike Force, its teams have shut down health care fraud schemes around the country, arrested criminals and recovered taxpayer dollars. As of June 1, Medicare Strike Force reported over 1,000 criminal actions and indictments and nearly $1.4 billion recovered funds. A few likely factors contributing to these results are agency collaboration, more stringent policies and practices, and increased and deliberate use of technology. Health care costs are directly impacted by Medicare and Medicaid fraud and consumers are the ones who suffer most. Incidences of fraud directly affect taxpayers and the businesses working to provide care for Medicare and Medicaid recipients. When systems are in place to ensure compliance, home health agencies benefit largely, and these benefits and cost reductions are then passed onto the patients and the taxpayers. Home health and hospice agencies’ revenues can be severely impacted by Medicare and Medicaid denials. Denials can come for several reasons, but most often result from improper billing through negligence, billing for procedures not performed or billing for visits that did not take place. Software technology is one area that has proved vital in the prevention and identification of fraud in health care generally, as well as home care and hospice agencies. For example, these agencies can implement an Electronic Visit Verification (EVV) system to verify care and assist with the billing process. Many home health agencies are using EVV apps on mobile devices such as smart phones and tablets to reduce the likely-hood of its clinicians documenting fabricated visits. Clinicians can use the app to electronically check in when arriving at a patient’s home, obtain the patient’s electronic signature and check out when exiting. Fraud is reduced by leveraging the mobile device’s GPS function to track the location of services and by recording the patient’s signature. Already, several states including Illinois, Florida, New York, Ohio, South Carolina, Tennessee, Texas and Washington mandate that home health agencies use specific technology to document that the patient home visit took place, as well as where and when the visit took place. More states are expected to follow suit in the near future. An EVV system is best combined with effective policies and procedures as well as a comprehensive, integrated home health software solution. Using this technology, home health agencies can be more profitable and can have more time to spend with patients. While fraud is still an issue, the practice is becoming less enticing for providers. The diligent efforts of governmental agencies combined with effective technology, policies and practices, have made health care fraud less prolific and will, potentially, reduce costs for consumers. Most importantly, those who need care will continue to get it, while new patients coming into the system benefit from legitimate practices.