Home Health Agencies / Special Fraud Alert - June 1995 / False or fraudulent claims

Why This Topic Matters

Home health agencies face significant exposure when claims, cost reports, referral arrangements, or business relationships are not handled properly. Understanding the government’s fraud concerns helps organizations identify compliance risks and reduce the chance of penalties, exclusion, or reimbursement problems.

Article Sections

1. False or fraudulent claims in home health

   Introduces the fraud alert and summarizes the major categories of improper claims activity discussed in the article. It also frames the government’s enforcement concerns in the home health setting.

2. Claims for visits not made or for ineligible beneficiaries

   Describes claims problems tied to home health visits that were not provided or were associated with beneficiaries who did not meet required coverage-related conditions. This section includes illustrative enforcement examples.

3. Subcontracted home health services

   Explains compliance concerns that can arise when home health agencies use subcontractors to furnish care. The section addresses oversight responsibility for billed services provided through outside organizations.

4. Medical necessity

   Discusses the importance of ensuring that billed home health services are supported as medically necessary. It also addresses the responsibilities of agencies and ordering physicians in this context.

5. Fraud in annual cost report claims

   Covers cost report reimbursement issues and the types of expenses that can create compliance problems in Medicare reporting. The section also addresses related-party disclosure concerns.

6. Paying or receiving kickbacks in exchange for Medicare or Medicaid referrals

   Reviews referral-inducement concerns under the Anti-Kickback Statute and describes several general forms of prohibited value exchange mentioned in the alert. It focuses on home health referral relationships involving multiple provider types.

7. Marketing uncovered or unneeded home care services to beneficiaries

   Describes aggressive marketing and solicitation practices that may lead to unnecessary or non-covered home health activity. The section highlights outreach to beneficiaries and pressure placed on physicians.