You play a vital role in protecting the integrity of the Medicare Program. To combat fraud and abuse, you must know how to protect your organization from engaging in abusive practices and violations of civil or criminal laws.

Home health & hospice care has long been recognized as vulnerable to fraud, waste, and abuse.

Medicare fraud typically includes any of the following:

• Knowingly submitting, or causing, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist
• Knowingly soliciting, receiving, offering, or paying incentives (e.g., kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by Federal health care programs
• Making prohibited referrals for certain designated health services

Defrauding the Federal Government and its programs is illegal. Committing Medicare fraud exposes individuals or entities to potential criminal, civil, and administrative liability, and may lead to imprisonment, fines, and penalties.

Examples of Home Health Fraud:

• Upcoding the types of services provided to receive higher payment
• Submitting bills for patients who are not homebound
• Visits by home health staff that are not medically necessary
• Home health visits that a doctor ordered, but the patient did not receive
• Bills for services and equipment a patient never received
• Fake signatures on medical forms or equipment orders
• Pressure to accept items and services that are not necessary or that Medicare does not cover
• Home health services provided that were not ordered by a physician
• A home health agency that offers free goods or services in exchange for Medicare numbers

Examples of Hospice Fraud:

• Offering the hospice benefit to a beneficiary who has not been certified by a physician to be terminally ill with a life expectancy of six months or less
• Inflating the level of care beyond what the patient actually needs, such as falsely documenting the patient needs crisis care to receive the highest reimbursement rates
• Providing gifts to beneficiaries to encourage them to agree to a hospice level of care (even though they are unlikely to be terminally ill)
• Ordering unnecessary equipment and medication
• Paying incentives for referral sources (such as physicians and nursing homes)
• Billing for a higher level of care than was provide.
• Billing the most expensive level of hospice care, or in-patient crisis care, when it is not medically necessary
• Failing to obtain a physician certification on plans of care
• Falsifying records to fake a physician certification
• Falsifying patient charts to justify admission or retention of patients
• High-pressure marketing of hospice services to ineligible beneficiaries
• Providing inadequate or incomplete services
• Improperly retaining hospice patients whose health is improving rather than declining
• Paying a bonus based on the volume of patients admitted
• Keeping patients on hospice care for long periods of time without medical justification
• Failing to conduct required patient re-evaluations
• Maintaining inadequate medical records that do not justify admission or retention
• Providing curative care to hospice patients

Where Should You Report Fraud and Abuse?

The A/B Medicare Administrative Contractor (MAC) Provider Outreach & Education (POE) developed this document to ensure consistent communication and education throughout the nation on a variety of topics and assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.