CMS Extends Home Health Enrollment Suspension to Combat Fraud

January 31, 2018 - In an effort to reduce Medicare fraud, CMS announced in a new rule that it will extend a moratorium on enrollment of new Medicare home health agencies in Florida, Illinois, Michigan, and Texas. The federal agency also suspended enrollment of new Medicare Part non-emergency ground ambulance suppliers in New Jersey and Pennsylvania.

The temporary halt of Medicare provider enrollment will also apply to new home health agencies and non-emergency ground ambulance suppliers seeking to enroll in Medicaid and the Children’s Health Insurance Program (CHIP) in the selected states.

CMS expanded the moratorium because healthcare fraud, waste, and abuse indicators were still present in the states.

“The circumstances warranting the imposition of the moratoria have not yet abated, and CMS has determined that the moratoria are still needed as we monitor the indicators and continue with administrative actions to combat fraud and abuse, such as payment suspensions and revocations of provider/supplier numbers,” the federal agency wrote in the rule.

For some counties in the selected states, CMS has enforced the enrollment suspension since 2013. CMS imposed moratoria in July 2013 to stop enrollment of new Medicare home health agencies in Miami-Dade County, Florida and Cook County, Illinois, and new Medicare Part B ground ambulance suppliers in Harris County, Texas.

Since then, CMS has extended and expanded the moratoria about every six months to continue combatting healthcare fraud, waste, and abuse in these and other states.

“In imposing these enrollment moratoria, CMS considered both qualitative and quantitative factors suggesting a high risk of fraud, waste, or abuse,” the federal agency explained. “CMS relied on law enforcement's longstanding experience with ongoing and emerging fraud trends and activities through civil, criminal, and administrative investigations and prosecutions. CMS' determination of a high risk of fraud, waste, or abuse in these provider and supplier types within these geographic locations was then confirmed by CMS' data analysis, which relied on factors the agency identified as strong indicators of risk.”

The federal agency also suspended enrollment of new home health agencies and ground ambulance suppliers in other federal healthcare programs. These provider types are likely to commit healthcare fraud in other programs if they participate in a Medicare fraud scheme, CMS claimed.

Medicare particularly targeted home health agencies as part of its healthcare fraud detection and prevention efforts. A 2012 HHS-OIG report found that Medicare inappropriately paid about $5 million for home health claims with errors. The errors included claims overlapped with inpatient hospital stay claims, claims overlapped with skilled nursing facility stay claims, and claim billed for services on dates after a beneficiary’s’ death.

The federal watchdog also reported that approximately 25 percent of home health agencies exceeded the threshold that suggested unusually high billing for at least one of the six questionable billing measures.

Home health agencies committing the medical billing errors primarily stemmed from Texas, Florida, California, and Michigan.

To combat healthcare fraud and medical billing mistakes, CMS issued temporary suspensions of new Medicare home health agencies in some of these states. The federal agency also initiated a pre-claim review demonstration for home health providers in five states in 2016 but decided to halt the program in April 2017 following concerns that the demonstration would impact care access.

Home health stakeholders have commended CMS in the past for fighting healthcare fraud in the home health space through the enrollment restrictions.

In 2014, the National Association for Home Care & Hospice’s (NAHC) former President Val J. Halamandaris stated, “NAHC has advocated for a moratorium on the certification of new Medicare home health providers in certain areas of the country where an overabundance of providers leads to potentially abusive practices. The extension and expansion of the home health moratorium is a necessary and appropriate measure.”

However, more recently, industry experts have questioned the longstanding moratorium on Medicare home health agency and non-emergency ground ambulance supplier enrollment.

Brian Werfel, a Medicare consultant with the American Ambulance Association, explained to Bloomberg BNA in May 2017 that the enrollment suspension extensions may be preventing innocent providers from joining Medicare and adding burdens on home health providers.

The most recent moratorium extension will remain in effect for the next six months.