CMS Tightens Screws on Home Health Fraud

The Centers for Medicare & Medicaid Services (CMS) is making strides to crack down on home health fraud through data use and more site visits, the agency announced Monday.

Recently released data could help CMS pinpoint more locations where it won’t certify new home health agencies in the future based on utilization patterns. CMS has already imposed a moratorium in certain areas and recently extended the ban for an additional six months, adding several cities to its list.

The new Moratoria Provider Services and Utilization Data Tool includes information on how many Medicare providers operate within a specific geographic region and the number of Medicare beneficiaries who use a health service area. It also points to utilization of certain services as compared to the number of providers in a given geographic region.


The analysis stems from paid Medicare claims data between Oct. 1, 2014 and Sept. 30, 2015 from the CMS Integrated Data Repository, which has Medicare and Medicaid claims, beneficiary data, provider data and plan data.

“CMS has used this powerful monitoring tool several times before to fight fraud, safeguard taxpayer dollars and protect beneficiaries,” Dr. Shantanu Agrawal, CMS deputy administrator and the director of the Center for Program Integrity, said in a statement. “By introducing data mapping for these specific, high-risk providers and suppliers in the moratoria areas and, for the first time, making service area data on all other [fee for service] providers and suppliers publicly available, analyses of the data offers additional insight for CMS and its stakeholders.”

The data tool includes an interactive map and a data set that depicts provider and supplier services at the national, state and county levels, as well as utilization data that could help CMS determine moratoria on new home health provider enrollments.


For example, a user can explore the map by different metrics, including the number of FFS beneficiaries; the number of providers; the average number of users per provider; the percentage of users out of FFS beneficiaries; and the average number of providers per county. The map identifies the states under moratoria—Florida, Illinois, Michigan and Texas—and allows users to zoom in to discover the counties specifically affected.

Among counties with fee-for-service home health beneficiaries, Borden County in Texas has the fewest, at 107, the data set shows. Incidentally, taken as a whole state, Texas has the most home health beneficiaries, at 2.53 million.

Los Angeles County in California is the county with the most fee-for-service beneficiaries, at 685,984. There are 750 certified home health providers in the county, with 125 users on average.

CMS also announced it intends to increase site visits, initially targeting providers and suppliers receiving high reimbursements by Medicare that are located in high-risk geographic areas, like those earmarked in the interactive tool.

“CMS is strongly committed to protecting the integrity of the Medicare program, including making sure providers and suppliers enrolled in Medicare are qualified and legitimate,” a news release states. “The Affordable Care Act provided tools to enhance our ability to screen and identify those providers and suppliers that may be at risk for committing fraud.”

Additionally, CMS will improve IT systems and monitor enrollment data on a monthly basis in an effort to deactivate providers or suppliers that meet certain criteria and have not billed Medicare in the last 13 months, according to the release.

Written by Kourtney Liepelt

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