Reliance on Unverified Patient Lists Creates a Vulnerability in Home Health Surveys

WHY WE DID THIS STUDY

Home health is a program area susceptible to fraud, waste, and abuse. To ensure that home health agencies (HHAs) comply with Medicare standards, Medicare requires them to undergo onsite surveys conducted by State survey agencies or accrediting organizations prior to initial enrollment and at least once every 36 months thereafter. As part of this process, however, surveyors use HHA supplied lists to select patients for review, prompting concern that HHAs could manipulate these lists to avoid scrutiny of certain patients.

HOW WE DID THIS STUDY

For selected high risk HHAs in three States, we collected HHA-supplied patient lists used by surveyors for recent surveys. We then compared these lists to Medicare claims data to identify any missing beneficiaries. We also conducted interviews with State survey agencies, accrediting organizations, CMS regional offices, and the CMS central office regarding processes for conducting surveys of HHAs and surveyors' use of HHA supplied patient lists.

WHAT WE FOUND

We found that some HHA supplied patient lists in our review were missing Medicare beneficiaries, allowing them to be excluded from surveyor reviews. We also found that surveyors cannot comprehensively verify that HHA supplied patient lists are complete at the time they conduct their surveys, creating a vulnerability that HHAs could exploit to conceal fraudulent activity or health and safety violations. However, existing data sources may be useful tools for both surveyors and CMS.

WHAT WE CONCLUDE

Looking ahead, we encourage CMS to explore the costs and benefits of actions it could take to mitigate the risk that this vulnerability poses and better protect Medicare and its beneficiaries. We have identified some potential strategies, including using existing data to provide better information for surveyors and conducting retrospective reviews.