It has become common to assert that home health is a hotbed of fraud, even within the industry. The opposite is true. The home health industry is a relative pool of integrity, and the objective data bears this out.
Since the Affordable Care Act authorized the Department of Health and Human Services to engage in large-scale fraud hunting and prosecution in 2007, their task forces have only “accused” $5 billion in fraudulent billing. To put that into perspective, home health agencies bill $19.5 billion per year. Since 2007, $5 billion would only be about 2% of overall billing. But wait, there’s more.
The Department of Health and Human Services (DHHS) states the $5 billion is “primarily home health care,” but also includes their investigations of mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services. The exact percentage of that $5 billion attributable to home health alone is unclear. Hypothetically, let us say 70% of that was home health. Now the percentage of *allegedly* fraudulent billing is down to 1.4%.
For those who have never been through a home health Department of Health inspection, it may be edifying to realize that alleged violations often need to be couched in terms of the Conditions of Participation in the Code of Federal Regulations. This can make the official report of violations sound much worse than they really are. For instance, nurses are often the professionals to determine the size of urinary catheter to use, not doctors. If nurses obtained signed orders to give a patient a urinary catheter, but forget to write what size catheters they would use in the order, a Department of Health inspector usually would not write up the agency for “failure to specify catheter size in doctor’s orders.” Specifying catheter size is not how the Condition of Participation is worded. Instead, the official report for this violation would say “Delivering care without doctor’s orders.” While this is clearly an overstatement, this more closely reflects how the Code of Federal Regulations is worded. Before 2007, an inspector would require a home health agency to create a correction plan and file that plan with the state. Since 2007, it seems more likely that the DHHS would label this behavior as “fraud.” It also seems more likely that Medicare would demand money back for the care that was delivered, even though the care was delivered well and the patient and doctors were fully satisfied.
Take note that not all of the $5 billion in fraudulent billing accused has been successfully prosecuted. These are alleged violations. Regardless of the successful prosecution rate, to judge an entire industry based on the behavior of 2% or less is bigotry. To put this in further perspective, roughly 3.1% of the American population has been convicted of a felony. If the correlate percentage in home health is 1.4% to 2%, home health has half the rate of felonious behavior compared to the general population. That makes home health a pool of integrity, not fraud. Fraud certainly exists as a small percentage in all realms of medicine, and the federal government certainly should take an active role in stopping that fraud. However, no person should confuse the anecdotes of successful investigations, the zeal of the fraud strike forces, or the hype in their press releases as evidence that home health is an industry riddled with fraud. Remember to gather the data and try to put anecdotes into perspective.