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Fraud. What is the evidence?

J Berek¹, N Gutierrez, J Stone

¹Health Care Financing Administration (HCFA), New York, NY 10278, USA.

Care Management Journals : Journal of Case Management ; the Journal of Long Term Home Health Care

|September 23, 2000

Summary

Medicare fraud and abuse initiatives targeted the home health industry due to perceived vulnerabilities and rising costs. This analysis explores the reasons behind these enforcement actions and supports their necessity.

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Area of Science:

Health Policy
Medical Economics
Healthcare Fraud

Background:

The home health industry faced scrutiny regarding Medicare fraud and abuse.
Legislation like Operation Restore Trust (ORT), HIPAA, and BBA were enacted during a period of vulnerability to reimbursement changes.
Concerns were raised about the basis of these initiatives, including controversial government studies and assumptions linking rising costs to fraud.

Purpose of the Study:

To summarize the reasons for the home health industry becoming a focus of Medicare fraud and abuse reduction efforts.
To provide evidence supporting the enforcement actions taken by the Health Care Financing Administration (HCFA) and its partners.

Main Methods:

Review of industry complaints regarding Medicare fraud and abuse initiatives.

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Analysis of legislative context, including ORT, HIPAA, and BBA.

Examination of government studies and assumptions cited by HCFA.

Main Results:

The home health industry perceived initiatives as a response to reimbursement vulnerabilities.
HCFA's actions were reportedly based on controversial studies and assumptions about cost increases.
The study aims to justify HCFA's focus and enforcement actions.

Conclusions:

The home health industry's vulnerability to reimbursement changes contributed to increased scrutiny.
The rationale behind HCFA's fraud and abuse initiatives warrants examination.
Evidence supports the necessity of enforcement actions in the home health sector.