May 2015 Fraud Prevention Fact

This month’s Fraud Prevention Fact deals with the topic of home health. Medicare’s home health benefit often is targeted for fraud and abuse. Before we get to some common home health fraud schemes, let’s look at how Medicare-covered home health is supposed to work. For home health, Medicare requires you to have an order from a Medicare-enrolled doctor or practitioner, and requires a physician or treating practitioner to have a face-to-face meeting with you.

That means for Medicare to cover it, you need to see a doctor to get an order for home health services.

Provided you and your provider meet the conditions, Medicare will cover these services: skilled nursing care; physical, speech or occupational therapy; medical social services; home health aide services; durable medical equipment; and some medical supplies.

In order to qualify for these services, you need to be homebound because of an illness or injury. You also must need specific skilled nursing services such as wound care, injections, ostomy care and tube feedings. Ordered physical therapy can include exercises, gait training and motion exercises.

Medicare does not cover housekeeping and will only cover personal care such as bathing and dressing if you are receiving it in conjunction with skilled home health care.

Now, what are common ways that fraudsters work? They bill for visits that never happened. They bill for more days than were provided. They bill for skilled care when no actual skilled care occurred. They bill for services that do not meet the criteria for home health such as help with cooking, cleaning, shopping or house chores. Sometimes they pay kickbacks for patient referrals, they alter records to falsify a doctor’s order, or they wrongly charge a co-payment, co-insurance, or deductible.

So, how can you protect yourself or your loved ones? First, when you are offered home health care, make sure it’s medically necessary and ordered by a Medicare-enrolled physician or provider. Know who you are dealing with. Second, do not sign blank documents or documents that falsely verify services. Know what you are signing. If at any point you have questions, ask! You may call Medicare at 1-800-MEDICARE or call the Missouri Senior Medicare Patrol (SMP) at 888-515-6565.

Your SMP can help you with questions, concerns, or complaints about potential Medicare and Medicaid fraud and abuse issues.  SMPs are funded through the U.S. Department of Health and Human Services, Administration for Community Living, Administration on Aging.

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