1. Bosler, Barbara JD, MHE, RHIA

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Recent home healthcare cases investigated through the Medicare Fraud Strike Force serve as a reminder of good documentation, coding, and billing practices to follow and how to direct patients to credible home healthcare and long-term care providers. The Office of Inspector General, U.S. Department of Health and Human Services (2015) has inventoried all the cases that the Medicare Fraud Strike Force has been involved with at: The Strike Force was created in 2007 as a multiagency team of federal, state, and local investigators to fight Medicare fraud. It currently operates in nine cities: Baton Rouge, LA; Brooklyn, NY; Chicago, IL; Dallas, TX; Detroit, MI; Houston, TX; Los Angeles, CA; and Miami-Dade and Tampa Bay, FL. It has been effective in charging almost 2,000 defendants for the fraudulent billing of more than 6 billion dollars under the Medicare program. Sadly, these cases represent the illegal practices of healthcare professionals including physicians and nurses, and span all healthcare provider types ranging from ambulance companies to pharmacies, to inpatient and outpatient healthcare facilities.

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Home healthcare fraudulent activity centers on illegal billing for services not medically necessary or not provided at all by both business owners of home healthcare agencies and/or actual providers including physicians, nurses, and physical therapists. Some of the more serious cases resulted in providers pleading guilty to multiple charges of conspiracy to commit fraud, falsifying documents to support false and fraudulent claims to Medicare, and falsifying documents to certify phantom patients for home healthcare. In most cases, sentencing of these individuals included prison time of months to years depending on the severity of the case, and paying restitution equitable to the millions of dollars they fraudulently billed under the Medicare Program.


Home Healthcare Eligibility and Choosing the Right Agency

Following the home healthcare cases reminds us how vulnerable certain patient populations are, the trust that they place in providers to give good direction on benefits they are entitled, and how consumers should choose the appropriate home healthcare agency. The Medicare and Home Health Care booklet, which is the official U.S. government resource for Medicare Home healthcare benefits, can be accessed at: Using this resource as a guide, Medicare eligibility criteria for home healthcare services, and best practices for choosing credible home healthcare agencies will be addressed in this month's column.


Under Medicare, patient eligibility for home healthcare is based on two broad requirements:


1. A physician must certify that the patient is homebound; and


2. The patient must need no more than part-time care.



Physician Certification

Homebound certification means that the patient is under the care of a physician with a plan of care that is regularly reviewed. The physician certifies that the patient needs one or more of the following services: (a) intermittent skilled nursing care; (b) physical therapy; (c) speech-language pathology; and (d) continued occupational therapy. Further, the physician must certify that the patient is homebound because of a disease or condition, and that assistance is needed to leave the home. Assistance can be in the form of another person, special transportation, or an assistive device. The physician should also document the considerable effort these patients expend to leave their home. The home healthcare agency caring for the patient must of course be Medicare-certified.


Amount of Service Needed

Medicare pays for home healthcare services when the patient has been certified and they need no more than part-time care. The formula used to measure this is the care given or needed on fewer than 7 days each week or less than 8 hours each day over a period of 21 or less days. Exceptions are considered for special circumstances.


Choosing a Home Healthcare Agency

Once a patient is certified, The Medicare and Home Healthcare (2010) booklet provides good resources in choosing a home healthcare agency. It offers the "Home Health Compare" web tool at, which allows the comparison of agencies in a specific locale by quality of care indicators met, services offered, duration of the company, and type of ownership. Further, a checklist for consumers provides good criteria when "shopping" for the right home healthcare agency such as: (a) Is the agency Medicare-certified? (b) Is the agency Medicaid-certified? (c) Does the agency offer the clinical and personal services needed by the patient? (d) Does the agency offer the language and cultural preferences desired by the patient? (e) Have background checks been run on the staff? (f) Does staff provide the type of care during the days and times desired by the patient? (g) Does staff provide nighttime, weekend, and emergency coverage? (h) Are patient satisfaction surveys from past and present time periods better than satisfactory?


Quality measures that should be specifically evaluated in comparing agencies include the percentage of patients: (a) getting better in meeting their goals; (b) experiencing less pain with movement; (c) who do not have relapses requiring more intensive care; and (d) whose wounds have improved or healed.


The National Association for Home Care and Hospice (NAHC) encourages using their Home Care/Hospice Agency link at to compare and contrast home healthcare agencies. This database contains information about more than 30,000 home care agencies. NAHC also offers some selection questions at to consider in deciding on an agency such as: how long the provider has been serving the community, and how involved the family is in developing the patient's plan of care.


In conclusion, there are many resources available for providers and patients to make good home healthcare decisions. The cases published on the Office of Inspector General's Web site serves as a powerful reminder to providers to not misuse public and patient trust.


Next month we will take a look at how home healthcare services are billed and what documentation should be present to support the services provided.




Centers for Medicare and Medicaid Services. (2010). Medicare and home health care. Retrieved from


National Association for Home Care and Hospice. How do I select the right home care provider? Retrieved from


Office of Inspector General, U.S. Department of Health and Human Services. (2015). Criminal and civil enforcement. Retrieved from[Context Link]