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News and Press: HCAF in the News

Rubio, Nelson United in Keeping Medicare Fraud Program Out of Florida

Wednesday, March 1, 2017   (0 Comments)
Posted by: Kyle Simon

By Christine Sexton, POLITICO (subscription required)

TALLAHASSEE — A program meant to ferret out Medicare fraud related to home health needs to be scrapped and not be expanded into Florida, Senators Bill Nelson and Marco Rubio told U.S. Health and Human Services Department Secretary Thomas Price in a letter.

The senators are leading a bipartisan effort by the Florida congressional delegation to prevent the Medicare Pre-Claim Review Demonstration project for home health from going into effect on April 1. The letter is signed by the entire congressional delegation, except for U.S. Reps. Matt Gaetz and Lois Frankel.

The lawmakers contend that federal investigators can find a "more effective program" to target fraud, and may jeopardize seniors' access to home heath services.

“Home health is a critical service for our constituents and the approximately 3.5 million seniors and people with disabilities on Medicare. It plays a vital role in treating patients in a clinically appropriate manner and in the location they most prefer — their own home,” write Rubio and Nelson in their letter sent Monday. “These patients are among the most vulnerable. They are typically older of lower socioeconomic status, and more likely to be disabled, a minority, or female than all other Medicare populations.”

Medicare pays 100 percent of home health care costs to qualified Medicare patients. Patients, for instance, must be confined to the home and must have a need for reasonable and necessary skilled nursing services.

Because Medicare generally does not verify claims or conditions before making a payment and there is no financial requirement on behalf of the patient, the home health services program has been rife with fraud. In fiscal year 2015, the improper Medicare payment rate for home health agencies was 59 percent. In 2016, rate was reduced to 42 percent.

Nevertheless, the efficacy of the program has been called into question after it was launched in Illinois. Home Care News reported last year that the The National Association for Home Care & Hospice received reports from members that the demonstration was riddled with problems and that Medicare administrative contractors doing the pre-claim reviews were losing electronically submitted documents. The trade publication also reported that the Medicare administrative contractors were issuing many rejections on the basis that the beneficiary is not home-bound or the care is not necessary.

Stephen Lee, a federal prosecutor in Illinois familiar with the pre-claim initiative said in January that the program is “limited” when it comes to catching someone who is lying.

Florida is considered ground zero for health care fraud. The Justice Department last Friday announced that 42-year-old Raciel Leon of Miami was sentenced to 126 months in person for his role in a $2.5 million Medicare fraud scheme.

In December, he was convicted of one count of conspiracy to commit health care fraud and wire fraud and one count of conspiracy to defraud the U.S. government and pay and receive health care bribes and kickbacks.

But Kyle Simon, director of government affairs for the Home Care Association of Florida, said the state has put controls in place that are cracking down on home health care fraud. He said his association is “not convinced there’s anything in the federal plan that demonstrates it's addressed fraud and abuse in a meaningful way.


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