1. Humphrey, Carolyn J. MS, RN, FAAN

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I've recently heard a few stories about home care nurses visiting physicians offering to pay for referrals, and nurses providing home care that didn't meet the Medicare coverage criteria of medical necessity. Is this fraud or abuse? Do you know for sure?


If you weren't in home care during the Operation Restore Trust (ORT) era, ask your colleagues and managers what it was like to work in home care at that time. A huge cloud of distrust hung over agencies, mainly enacted by the U.S. Congress whose members had supported home care and subsequently felt betrayed by providers, including clinicians.


In June the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS) released two reports concerning its efforts to fight fraud and abuse in the federal health system. OIG's "Semi-Annual Report to Congress October 2002-March 2003: Working with Others to Promote, & Protect Our Nation's Well-Being" chronicles more than $12 billion in savings as a result of OIG fraud enforcement measures taken during the first 6 months of fiscal year (FY) 2003.


OIG also released the 2003 edition of The Red Book, containing recommendations for cost savings from CMS. If implemented, many of the Red Book recommendations would impact home health and hospice providers and home medical equipment (HME) suppliers.


In its semi-annual report, the OIG noted exclusions of 1,241 individuals and entities for fraud or abuse of the federal healthcare programs and/or their beneficiaries, 320 convictions of individuals or entities that engaged in crimes against departmental programs, and 106 civil actions. In the area of home health, the OIG cited cases of kickback for patient referrals and the filing of false claims.


OIG audits and investigations have identified medically unnecessary care and inappropriate billing in home care as well as extreme billing variations that raise questions about the appropriateness of some billing. This lead the OIG to require a physician examination before a person can order their own home health services.


For hospice, the OIG specifically recommends CMS consider imposing sanctions on physicians who erroneously certify beneficiaries for hospice services. We all know how difficult it is to estimate a terminally ill person's life expectancy.


Remember, committing fraud and/or abuse in the Medicaid program is a Federal Offense; if you are found guilty, you face incarceration and are a convicted felon for the rest of your life. Please read the article on fraud and abuse in this issue to learn how to protect yourself-we can't repeat the problems of the past and you can't plead innocent because you "didn't know."


The OIG Red Book is available at The semiannual report is available at


Note:Information for this editorial was gathered from NAHC Report Online No. 1014: Friday, June 6, 2003,