When it comes to home healthcare, fraud and theft are major areas of concern. Every effort must be made to prevent fraud and theft, as occurrences not only affect the well-being of patients, but can also harm a client’s reputation.
Health care fraud occurs when false information is represented as truth. Perpetrators exploit patients by entering into their medical records false diagnoses of medical conditions they do not have, or of more severe conditions than they actually do have. Then bogus insurance claims can be submitted for payment.
Home healthcare fraud claims also involve intentional incorrect billing of Medicare. According to the Senior Medicare Patrol (SMP), “An estimated $250 million is lost to purposeful health care fraud each year.” Examples of fraud that may occur include:
- Billing Medicare for patients who do not qualify as someone who is homebound according to Medicare standard
- Billing for care that was not provided or was unnecessary
- Billing the client a co-pay (Medicare does not charge co-pays for services other than for medical equipment)
- Incorrect medical history entered on patient records
- Bribing a healthcare provider to classify someone as homebound to meet Medicare standards
- Unbundling – billing each step of a procedure as if it were a separate procedure
The risk of theft occurring is prevalent for home healthcare, because services are provided in the private homes of clients. Those providing services have no direct supervision and are not monitored, as they would be in an elder care facility.
Agents can help their insured home healthcare clients prevent fraud and theft by encouraging them to take the following steps:
- Require pre-employment background checks to mitigate the risk of previous criminal activity such as fraud, embezzlement, or abuse.
- Stress a strict no tolerance policy for theft, fraud and related behavior in the employee handbook, and reemphasize it during training and continuing education.
Additionally, agents should discuss with their insureds the response they can expect in the event of a claim. They need to be aware of the type of protection they have when dealing with employee theft, forgery or alteration, or fraud.
In the event of an occurrence of fraud or theft, agents should do the following:
- Prepare the home healthcare client to deal with the press. Your insured can be better prepared to mitigate damage to their public image if they take due diligence to provide protection and build a positive reputation before the claim occurs.
- Discuss implementing a risk management plan to prevent such claims and as a way to eliminate further occurrences.
As in so many cases, preparation and planning is the key to preventing problems with fraud and theft. Understanding the potential problems home healthcare providers may encounter, initiating an appropriate plan for prevention, and knowing how to respond in the event a claim does occur will provide your agents and their clients with the tools necessary help mitigate the risk of fraud and theft.
At Highland Risk Services, we understand the unique needs of home healthcare and can provide you and the clients you serve risk management to prevent losses from fraud and theft. In addition, we can help you provide the home healthcare coverage requirements for your clients. Please call us at one of our offices in Chicago at 847-832-9100, Lansing at 517-676-7100 or Phoenix at 947-832-9099.