Michigan Medicare House Calls: What’s All The Fuss?

USA Today reports that the state of Michigan lays claim to over $60 million in fraudulent billings by Michigan doctors who have made house calls since 2012. Although incidences of fraud are on the rise, the demand for home visits may supersede the fraud and abuse problems Medicare has experienced with house calls.

Background

Patients too debilitated to leave their homes typically have more chronic health problems than the average office visit can handle. To qualify for services under Medicare’s home health care program, a doctor must certify that a patient is homebound. The home visits are billed by the complexity of the case and by the amount of time the physician spends with a patient. The problem, however, is that doctors are not always monitored while at the patient’s home, which causes concerns about confirming that the services billed for were actually provided.

Case for Fraud

United States Assistant Attorney General Leslie Caldwell noted that there has been a marked increase in both home health providers and fraud in Michigan, because Michigan is one of five states that does not license home health care agencies. According to Caldwell, 14 Michigan doctors have recently been indicted in fraud cases involving home visits in which physicians’ visit hours were exaggerated or patients were referred to home health agencies when there was no medical necessity to do so.

In 2012, Michigan physicians ranked first in the country for receiving Medicare funds for home care visits; the more than $39 million they received equaled 42 other states’ funding combined. while Illinois came in second with $21 million. Seventy percent of home visits were billed at the two highest-level codes.

Case Against Fraud

Home visits have been shown to reduce the likelihood of repeat hospital stays and drive down overall Medicare costs. The executive director of the American Academy of Home Care Medicine, Constance Row, noted that her agency’s data shows that although 4 million Medicare patients had a medical necessity for house calls in 2012, only 620,000 received one visit. Row said, “It’s an underserved population. If a few more people in Michigan are getting service, then good for them.” She added that physicians and nurses are not reimbursed for their travel costs to and from patients’ homes.

Physician home visits further benefit homebound Medicare patients because physicians are able to assess seniors’ living conditions and help ensure that they have proper nutrition and hygiene at their homes.

Some Solutions

Some home health agencies have implemented policies and procedures to prevent the potential for fraud, including the use of strict internal controls; GPS monitors that record the length of physicians’ and medical assistants’ visits; and detailed quarterly reports.

According to USA Today, Medicare is sponsoring a three-year demonstration project as part of the Patient Protection and Affordable Care Act (ACA) (P.L.111-148). The project provides financial incentives to 18 medical practices and partnerships that service seniors at home. If Medicare determines that the provided home care saves money by reducing the need for more costly types of visits, such as emergency room visits, then the practice or partnership will be allowed to keep a portion of the savings.

Such initiatives may help to reduce the number of fraudulent incidences for many of Michigan’s home health agencies and physicians who make house calls.