CMS makes additional payments, known as outlier payments, to compensate
HHAs that supply services to beneficiaries who incur unusually large costs.
However, in 2008 a number of HHAs in Miami-Dade County accounted for
more outlier payments than did HHAs in the rest of the Nation combined.20
In an attempt to mitigate vulnerabilities associated with outlier payments, in
2010 CMS capped outlier payments to individual HHAs at 10 percent of
each HHA’s total home health payments.
To increase physician involvement with Medicare home health beneficiaries,
as well as to provide additional clinical oversight for HHA-provided care,
the ACA requires that physicians (or certain practitioners working with the
physician) who certify beneficiaries as eligible for Medicare home health
services have face-to-face encounters with those beneficiaries. Such
encounters must occur within a 120-day window: either within the 90 days
before beneficiaries start home health care or up to 30 days after they start
care. The signing practitioner must document who saw the patient and the
date of the encounter; the practitioner must also describe how clinical
findings support the beneficiary’s eligibility for home health services. CMS
gave HHAs until April 1, 2011, to comply with this requirement.
Health Care Fraud Prevention and Enforcement Action Team
In 2007, HHS and the Department of Justice (DOJ) established the joint
Medicare Fraud Strike Force, which was designed to combat fraud
through the use of Medicare data analysis and an increased focus on
community policing.25 Building on the success of the Strike Force, in
2009 HHS and DOJ established an interagency Health Care Fraud
Prevention and Enforcement Action Team to combat health care fraud
nationwide.26 Now operating in 9 cities, Strike Force efforts have resulted
in charges against 213 individuals or entities, 107 convictions, and
$63.9 million in investigative receivables.
For example, on July 13, 2011, a manager and a registered nurse from an
HHA pleaded guilty to participating in an alleged $25 million Medicare
billing scheme.28 The two individuals falsified patient records to make it
appear as though beneficiaries qualified for home health care and therapy
services.
