Apparently CMS is going to launch a pilot investigation in Florida and my peer is giving us a heads up on this. You'll find below a media message he received, his response and NAHC's response. This is just an FYI. Media: This is Virgil Dickson a reporter at Modern Healthcare. The CMS is planning to launch a pilot investigation so it can develop a better sense of just how bad Medicare fraud is in the home health industry. They say that despite the publicly cited estimates of fraud, a statistically valid estimate of the rate of fraud in Medicare does not currently exist. The pilot will focus on Florida to start, and shall estimate the incidence of potential fraud in the Medicare fee-for-service program in the service category of home health care. The goal of this program is to develop an approach to estimate the fraction of Medicare payments for home health services that exhibit behavior consistent with fraudulent activities, as determined by expert opinion informed by a review of records and interview information. I'm attaching the announcement, and I wanted to see if I could get a comment from you on its implications. I'm hoping to wrap the story by 2 est. Bobby Lolley, FL Exec Dir: Mr. Dickson Please see my comments and statement below. Feel free to call me if you need any additional information or clarification. Thank you for the opportunity to express our thoughts and feelings on this initiative. As the association that represents the home care industry in Florida, we feel any program that helps CMS more accurately measure fraud in the home health system to be a very positive step in the right direction. We celebrate the removal of these harmful providers in order to uphold the name of the thousands of home health agencies in Florida working every day to serve patients in the most caring, cost-effective way, and in the very place that patients want to be served the most: their homes and communities. With that said, we find it very concerning that CMS would choose one of the most highly investigated regions in the country to begin this program. Since the Health Care Fraud Prevention and Enforcement Action Team (HEAT) was established in Miami-Dade County, the number of home health agencies in the area has fallen from 958 in 2009 to 471 today, or a closure of over 50% of agencies. Out of the agencies left, the vast majority are honest businesses providing excellent care, but they continue to bear the burden for the few bad actors that remain. Currently, there are 240 Medicare Certified Agencies, which cannot increase due to a federally enacted moratorium on new Medicare agencies in Miami-Dade. With over 400,000 Medicare beneficiaries in the county (and that number rising), it is clear that there is a need for a certain level of home and community based services to adequately serve this large population. If the goal of this pilot is to more accurately measure home health fraud in a system that could be applied to the rest of the country, we find fault with CMS beginning in Miami-Dade County. It would seem that the intended result is to try to yield a higher number in order to justify increased scrutiny on good providers all over Florida and throughout the country. We would ask CMS to look at a much broader slice of providers in our state, including different municipalities across several regions. Whether CMS finds that fraud accounts for 3% of home health payments or more, there should be a zero-tolerance policy for any fraud and we would encourage CMS to specifically target and force those bad providers out of business, but we cannot support a program if the intention is to raise a false flag of rampant criminal activity over an industry that does not deserve that designation. If these findings will be used to validate a process that will be applied nationwide it is irresponsible of CMS to not make it the best that it can be at this early juncture. Miami Dade may make for good headlines, but it does not make for a good sample data set that will represent the entire industry. Bill Dombi, NAHC: Aside from concerns about the design of the project, the main question is whether the project serves any real useful purpose. Does it truly make a difference whether the incidence of fraud is 3% or 5%? There should be zero tolerance for health care fraud. The focus on Miami-Dade is very interesting as there has been a H.E.A.T program in that metropolitan area for several years that is routing out fraud in home health services. Why focus this "study" on a geographic area that has been fully investigated already? Fraud in Miami-Dade should be prosecuted, not studied to determine what is the best estimate of its depth. I highly doubt that any findings from such study would be of value in rooting out fraud given the intensity of investigations that have already occurred. NAHC is a vigorous proponent for aggressive and targeted program integrity measures. It is not that we oppose such a study, it is a question as to whether this is the best use of limited resources.
