Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases

WHY WE DID THIS STUDY

Home health has long been recognized as a program area vulnerable to fraud, waste, and abuse. OIG home health investigations have resulted in more than 350 criminal and civil actions and over $975 million in receivables for fiscal years 2011-2015. Additionally, previous reports from OIG and the Government Accountability Office have raised concerns about questionable billing patterns, compliance problems, and improper payments in home health.

HOW WE DID THIS STUDY

We analyzed Medicare claims data from calendar years 2014 and 2015 to assess the national prevalence and distribution of selected characteristics commonly found in OIG-investigated home health fraud cases. We identified HHAs and supervising physicians that were statistical outliers with regard to those characteristics in comparison to their peers nationally. We also identified geographic "hotspots" that were either statistical outliers compared to other areas nationally or contained significant numbers of HHA or physician outliers.

WHAT WE FOUND

Our analysis identified a substantial number of providers-over 500 HHAs and over 4,500 physicians-that were outliers in comparison to their peers nationally with respect to multiple characteristics commonly found in OIG-investigated cases of home health fraud. It is important to note that our analysis does not demonstrate that these providers were engaged in fraudulent activity. Our analysis also identified 27 geographic hotspots in 12 States-i.e., areas where characteristics commonly found in OIG home health fraud cases are prevalent. Many of these hotspots are areas already recognized as having high rates of Medicare fraud.

WHAT WE CONCLUDE

Along with OIG's existing body of work, the results presented in this data brief demonstrate that home health fraud in Medicare continues to warrant scrutiny and attention from OIG, its law enforcement partners, and the Centers for Medicare & Medicaid Services (CMS). Past OIG and CMS efforts have been successful in reducing Medicare home health spending, and OIG is committed to continuing its fight against home health fraud, waste, and abuse through additional investigations, audits, evaluations, and enforcement actions. It is also essential for CMS to continue to use the tools at its disposal to prevent home health fraud and to assess whether further actions are needed.

This data brief is being released in tandem with an OIG Alert, which focuses on improper arrangements and conduct by HHAs and physicians.