Home Health Fraud: Eligibility, Documentation and Referral Kickbacks
Home health fraud includes billing for beneficiaries who do not meet the homebound requirement, certifying medical necessity without a supporting face-to-face encounter, upcoding visits, and paying kickbacks for referrals. Our attorneys have recovered in both upcoding and referral kickback matters in this sector.
The eligibility rules that get bent
Medicare home health coverage requires that the beneficiary be homebound, that the services be reasonable and necessary, that a physician certify the plan of care, and that a face-to-face encounter support the certification.
Each requirement is a certification, and each is a place where a claim becomes false. Homebound status is the most frequently stretched, because it is a clinical judgment that is easy to characterize loosely.
The patterns enforcement finds
Home health cases cluster around admissions, documentation, and referral economics.
- Admitting beneficiaries who are ambulatory and independent as homebound
- Face-to-face encounter documentation created to support a certification already made
- Recertifying episodes without a clinical basis to extend billing
- Upcoding visit intensity or therapy utilization to reach a higher payment tier
- Paying physicians, discharge planners, or marketers for referrals
- Billing for visits that did not occur or were performed by unqualified staff
Two matters our attorneys handled
Our attorneys recovered several hundred thousand dollars in a whistleblower action alleging a home health provider defrauded federal healthcare programs through upcoded billings.
In a separate matter, our attorneys recovered several hundred thousand dollars in an action alleging kickbacks paid by a home health care provider to induce referrals.
The clinicians see it first
Field nurses and therapists know which patients are genuinely homebound, because they walk into the house. Intake coordinators know which referrals came with an expectation attached. Billing staff see the codes that do not match the visit notes.
Frequently asked questions
What does homebound actually require?
That leaving home requires considerable and taxing effort, and that absences are infrequent or for medical treatment, with limited exceptions. A patient who drives to social activities generally does not qualify.
The physician signed the certification. Is the agency still liable?
Yes. An agency that submits claims knowing the certification is unsupported can be liable, and the certifying physician can be as well, particularly where the agency prepared the documentation.
Are marketing payments to referral sources allowed?
Payments to induce referrals of federally reimbursed services implicate the Anti-Kickback Statute. Bona fide employment and personal services arrangements at fair market value that do not vary with referral volume can be structured lawfully.
The attorneys who handle these cases
Related reading
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