Article Content

What is the fraud and abuse in question? A home health agency is paying several physicians to serve as their medical directors who are never around, yet seem to get most of their referrals. Another agency conveniently maintains almost every patient for a second episode. A diabetic patient reports that her neighbor is now having the home health nurse give her insulin injections twice a day although she still seems able to self-inject. These are all indicators of a potential problem with abuse of the Medicare home health benefit. While there are dramatic criminal cases of fraudulent agencies billing for patients that do not exist or home health services ordered by dead physicians, there are a wide range of situations in which the Medicare home health benefit is being overcharged and abused by unethical providers. Sadly, the Medicare home health benefit once again seems to have attracted some marginal providers that are either ignorant of the rules or who have decided to circumvent them in the pursuit of quick money. While these problems seem to be concentrated in certain parts of the country, history has shown us that unless program abuse is controlled it will spread.


But as an employee of an ethical and compliant agency, it would be fair to ask, "Why should I care? I'm a clinician or administrator with more than enough on my plate trying to do the best job I can for our patients." VNAA asked a very similar question of itself and our members. It also pondered whether involving ourselves in an effort to get tough on Medicare abuse would somehow increase the perception that home health was full of criminals or increase the burdens on ethical agencies. We asked this question of our members and solicited specific suggestions that VNAs would support. VNAA and its members concluded that the risk to our patients and our agencies by remaining silent on this issue was far greater than any misunderstanding of our intent. It was worth the additional work it might take to differentiate high quality, ethical agencies. Therefore, VNAA and its members developed a White Paper called "Medicare Home Health: Encouraging Quality and Discouraging Abuse" and presented it to Centers for Medicare and Medicaid Services (CMS). [Go to to review a copy of the document.] It contains 33 specific recommendations for changes in home health medical review, provider enrollment, payment policy and the conditions of participation that are intended to raise the quality bar for home healthcare agencies and discourage the continued participation of agencies that abuse the Medicare program.


In this paper, VNAA states: "While most home health agencies (HHAs) provide high-quality home healthcare and comply with Medicare policy, abusive and even fraudulent conduct by a minority of Medicare certified HHAs threatens the quality of patient care, drives up Medicare costs and undermines the perceived value of home healthcare."


Returning to the core question of: Why is it our problem? In an era of limited financial resources and budget neutrality, every dollar being diverted to abusive providers is a dollar removed from the resource pool for providers serving legitimate beneficiary needs. A significant number of Medicare home healthcare providers have negative or low margins while an equally high number have very high margins. In markets that have become saturated with agencies, the competition for referrals is fierce. Yet cherry-picking behavior leads intensive care patients uncared for or accepted by agencies willing to subsidize their care, thus allowing competitors to bank high margins.


Over the past several years, both CMS and Congress have implemented a variety of across-the-board payment freezes or cuts in an effort to control excess costs driven by program fraud and abuse. The logical consequence of continued across-the-board cuts in this vulnerable home health environment is not that abusive providers will be driven out, but that the content of the benefit will shrink and legitimate providers will either mimic the behavior of abusive providers or be slowly edged out of existence. Nonprofit VNAs view this as unacceptable and a direct threat to their community service mission, their legacy as the founders of home healthcare and to the best interests of Medicare beneficiaries.


The VNAA representing VNAs and nonprofit HHAs believes that home healthcare offers Medicare the best chance to meet the needs of the aging generation cost-effectively. However, abusive conduct by a small segment of the home health community is diverting public attention from the opportunity to use home-based healthcare as an alternative to more costly institutional care for persons in the advanced stage of chronic illness. The VNAA urges all parties in government that share responsibility for the Medicare program and the healthcare of the vulnerable population it serves to join with VNAA and the larger home health community in a united effort to drive abusive practices out of this industry.