August 12, 1997 in City

Medicare Fraud Witch Hunt Won’t Serve Anyone’s Interests

Sheila Masteller Special To Roundtable

Recent Congressional hearings and releases of government findings have resulted in a stream of news stories about “fraud and abuse” in the Medicare program, particularly in home care. They paint a picture of a system that is growing too fast, has too many providers, provides unnecessary care and has little or no oversight or accountability.

While there is evidence of abuse within the industry - particularly in states that have few if any protections built in - I caution that it’s unfair and inaccurate to make assumptions about an entire industry.

In the late 1980s, the Home Care Association of Washington proposed and worked to pass a comprehensive, mandatory licensure law. Washington is one of only 12 states that require licensure for all home care agencies.

Washington is also one of only 20 states that require a Certificate of Need, wherein home health agencies must demonstrate a need for their services, competency in providing care and financial viability before they can provide care to Medicare patients. This explains why Washington has 70 Medicare-certified home health agencies compared to non-certificate of need states such as Oklahoma, which has 386 agencies, and Louisiana, which has 520. Many of the states experiencing problems with home care fraud have too many agencies serving the Medicare population and little or nothing in the way of safeguards concerning who can start a Medicare-certified agency.

Additionally, Washington is one of only 15 states that requires criminal background checks for all home care agency owners and employees.

An article in the July 27 Spokesman-Review quoted the U.S. Department of Health and Human Services inspector general as stating that “up to one-third of Medicare payments to home health care agencies in some states were improper or unjustified.”

Between licensure and certificate of need, Washington has built-in protection from most of the kinds of fraud and abuse the U.S. Office of the Inspector General has noted elsewhere. A comparison of average visits per home health patient with Medicare insurance shows that Washington state is the fewest in the nation, with 33 visits per patient, as compared to the national average of 70. Some Southern states have over 100 visits, based on 1996 data.

The Spokane Visiting Nurse Association, or VNA, a local nonprofit home health agency, provides an average of 25 visits per patient for a Medicare patient.

While there are always opportunities for increased efficiencies, cutting the number of visits for some patients would jeopardize their safety and possibly lead to costly hospitalizations.

VNA has worked hard to hold down costs, even during times when the government allowed much higher charges. For instance, VNA’s cost per Medicare visit has been more than 30 percent below the government allowed maximum for the past five years.

At VNA, we undergo rigorous scrutiny of our finances and patient care services’ compliance with federal and state regulations. There is an extensive financial audit annually by our Medicare oversight organization as well as by an independent accounting firm for review by our volunteer board of directors, whose members represent the community. As a Spokane County United Way member agency, VNA’s services and financial information are reviewed each year by a panel of United Way volunteers.

In addition, patient care is evaluated each year by a state surveyor, who reviews patient files, employee files and accompanies staff on home visits. Last year, VNA had absolutely no problem areas or areas needing improvement cited during our state licensure and Medicare certification surveys.

At VNA, we have zero tolerance for individuals or agencies that violate the public trust. It is important, howwever, to share my concerns about the effects of Operation Restore Trust, which is the name of the federal effort to find and eliminate fraud and abuse in Medicare. What began as an effort to uncover misuse of tax dollars seems to be snowballing into an attempt to present every human error, no matter how small, as fraud.

In some Operation Restore Trust audits, a nurse’s chart note accidentally dated one day early or late was used as a reason to label it as a fraudulent visit, even though the care was necessary and provided as ordered by the physician, in compliance with Medicare regulations. I do not believe this type of error is what most people would call fraud.

In other areas of the country, charitable home care agencies with decades of outstanding service have very nearly been destroyed by overzealous audits that found some documentation errors but no intent to defraud the government.

Do taxpayers really benefit when legitimate providers are no longer able to serve the public - particularly when they have provided years of quality care and were conscientiously working to follow federal guidelines? Who will take over their charitable mission of serving people without insurance or the financial means to pay for care?

My greatest concern is for the many frail and sick elderly people who depend on quality home health services. They are at risk from the backlash of a search for fraud and abuse that is growing increasingly strident and seems to operate on the assumption that every Medicare provider has something to hide.

The vast majority of home health agencies in our state are not only legitimate and free of fraud, but also highly competent, caring and cost-effective.


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