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U.S. Tags 12 States as Fraud Hotspots for Home Health Services

By Eileen K. Leslie, CPA, CFE

February 27th, 2017


While the majority of home health providers are devoted to the needs of their ill or elderly patients, the industry has long been plagued by criminals gaming the system. The most common types of fraudulent activity typically involve billing for services that are either not medically necessary and/or never provided. 

Questionable billing practices, improper payments and compliance issues also factor into the government’s vast responsibility to ensure that Medicare’s vulnerability to fraud, waste and abuse is mitigated, according to a recent report from the U.S. Department of Health & Human Services Office of Inspector General (“OIG”) titled, “Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases.” 

Between fiscal years 2011 through 2015, government investigations into home health fraud resulted in some 350 criminal and civil actions and $975 million owed to the government. 

In 2015 alone it’s estimated that Medicare made more than $10 billion in improper payments to home health agencies. 

The opportunity for home health fraud is widespread since the array of Medicare-covered home health benefits is vast, including services such as skilled nursing care, home-based assistance and therapeutic services for qualifying homebound individuals, the report states. 

The OIG analysis identified 12 states — Arizona, California, Florida, Illinois, Louisiana, Michigan, Nevada, New York, Oklahoma, Pennsylvania, Texas, and Utah — as “geographic hotspots.” In 2015, “35 percent of all home health episodes and 37 percent of all home health spending” occurred in these hotspots. 

In addition to the states that are singled out, the OIG lists other red flags for fraud, such as a “high percentage of episodes for which the beneficiary had no recent visits with the supervising physician” and a “high percentage of episodes that were not preceded by a hospital or nursing home stay.” 

High percentages of beneficiaries with claims from multiple home health agencies and/or multiple home health readmissions in a short period of time can also be indicators of fraud or abuse. 

Whistleblowers filing qui tam cases play a key role in uncovering healthcare fraud. 

Presenting the government with an organized and cogent case offers False Claims Act (FCA) relators the best chance for their case to be accepted. 

During my four years as a financial analyst and government financial expert at the U.S. Attorney’s Office performing forensic financial analysis and calculating damages on civil False Claims Act cases, including those initiated by government agencies, I handled many Medicare fraud investigations. 

Having an expert with direct knowledge of the procedures, process and financial documentation needed by the government to pursue False Claims Act litigation is an extremely valuable tool. 

My experience in forensic auditing and investigative accounting for the Federal Bureau of Investigation, the U.S. Attorney's Office, and public accounting firms provides me with unique perspective and insight to add value to qui tam investigations. 

As a Certified Fraud Examiner and CPA, I work with qui tam attorneys in the following ways: 

  • Analyzing cases with a comparable threshold the government will typically use in making its determination;
  • Determining the strengths and weaknesses of a claim and identifying any areas for improvement in the case;
  • Exploring methodologies and calculating FCA damages (statistical sampling, etc.);
  • Collaborating with counsel to organize and prepare FCA case materials in a format that clearly and concisely articulates the case to the U.S. Attorney’s Office and the court. 


About Investigative CPA, LLC 


Investigative CPA, LLC, founded by Eileen K. Leslie, specializes in False Claims Act (FCA) investigations on a national basis. 

Ms. Leslie is a Certified Public Accountant (CPA, 2004), a Certified Fraud Examiner (CFE, 2007), and holds a Master of Taxation (2003). She worked for the Department of Justice in both the United States Attorney’s Office (2010 to 2014) and the Federal Bureau of Investigation (FBI, 2004 to 2007). Additionally, she has held positions in public, private and forensic accounting firms. She is also a proud United States Air Force veteran. 

She works closely with qui tam attorneys and government agencies nationwide to investigate FCA claims, uncover fraud, calculate damages, and provide forensic financial consulting services. She strives to achieve maximum recovery of damages to the government and other injured parties, when appropriate. 

Beyond FCA investigations, Ms. Leslie has performed a variety of criminal fraud investigations and non-government civil fraud examinations and fraud assessments. She has also investigated violations of the Anti-Kickback statute and the Stark Law. 

Contact Ms. Leslie at 205-660-0322 or email to discuss a potential whistleblower case or other fraud matter. 

Disclaimer

This article is provided for educational purposes only. It is not intended to provide legal advice or an opinion in regard to any topic discussed. The blog should not be used as a substitute for legal advice from a licensed attorney in your state.

Material for this article was taken from a collection of industry sources relating to the subject. Every case is different and circumstances vary widely depending on the governing state or federal law, policy provisions, and related considerations