Between 2011-2015, Office of Inspector General investigations have resulted in more than 350 criminal and civil actions and $975 million in receivables.  The OIG and Government Accountability Office have raised concern about questionable billing patterns, compliance problems, and improper payments in home health. In the course of their investigations, OIG has identified over $10 billion in improper payments in FY 2015.

OIG has further reported that more than 500 home health agencies (HHAs) and 4,500 physicians demonstrated multiple characteristics commonly found in OIG-investigated cases of home health fraud.  These “characteristics” are now employed by OIG to monitor HHAs for fraud, waste and abuse.

Here, we briefly list the “characteristics commonly found in OIG-investigated cases of home health fraud.”  Understanding and monitoring these characteristics enables HHAs to proactively prevent OIG investigations or identify instances of fraudulent or fraud-like activities.

Characteristics Signaling Fraudulent Activity

  1. High percentage of episodes for which the beneficiary had no recent visits with the supervising physician
  2. High percentage of episodes that were not preceded by a hospital or nursing home stay
  3. High percentage of episodes with a primary diagnosis of diabetes or hypertension
  4. High percentage of beneficiaries with claims from multiple HHAs
  5. High percentage of beneficiaries with multiple home health readmissions in a short period of time

Geographic Hotspots

OIG identified hotspots in 12 States for exhibiting characteristics commonly found in OIG home health fraud cases.  These hotspots were located in California, Nevada, Utah, Arizona, Texas, Florida, Louisiana, Oklahoma, Illinois, Michigan, Pennsylvania, New York.