Medicare anti-fraud rule disrupts South Florida senior care
Crackdown on home health fraud causes ripple effect
Home health nurse Henrietta Jacobson used to visit a disabled diabetic in Fort Lauderdale twice a day to give him insulin shots, enough help so he could keep living on his own.
No more. The man, about 70, moved to a nursing home because of a new Medicare rule to fight rampant home health fraud, especially in Miami.
The new rule caps how much home-care companies can make from Medicare patients who need more than one visit a day. The change prompted the family of Jacbobson’s patient to move him, out of fear that his home-care company would drop him.
More cases like his are cropping up in South Florida, home health officials said. Most in the business favor the new rule but worry that some seniors are being affected.
“This is going to push more people into nursing homes, and that’s not good for them,” Jacobson said. “I don’t think this is going to save money. It’s going to cost more money.”
Medicare said some unscrupulous home health firms, many in Miami, abused the health system for seniors and disabled adults by creating fictitious patients and billing for multiple daily visits, because the government pays much more for them. Other firms took on large numbers of those patients to boost profits.
As a result of the new rule, some firms are dropping a portion of their costly patients, and many other firms are reluctant to take them, according to officials at eight home care companies. A few of the 96,700 South Florida seniors who rely on home care are struggling to find new providers, and nurses have been looking for companies to take patients who are dropped.
“This happened because of greed by some agencies,” said Patricia Montalvo, administrator of Associated Home Health, a Fort Lauderdale company. “We hate to see the patients bear the burden because [agencies] made bad decisions, but now there will be some good people who will be hurt.”
Federal and state officials, and some home care owners, said hardships from the new rule have been few. “Patient dumping” laws prevent firms from dropping seniors without helping place them with another firm, they said. Seniors can report violations by calling Medicare at 800-633-4227 or the state at 888-419-3456.
“No patient is going to be without services — if they qualify for services,” said Cecilia Franco, director of Medicare’s investigative office in South Florida. “We have taken every single precaution.”
The Florida Agency for Health Care Administration is investigating at least one complaint of patient dumping, said Polly Weaver, statewide chief of field operations.
No one disputes that Medicare fraud is a huge problem in South Florida, costing an estimated $3 billion a year. Widespread phony billings and overpayments for wheelchairs, diabetic supplies, walkers and other medical equipment led Medicare to require suppliers to bid for the right to sell the items in 2011. Suppliers are pushing Congress to kill this requirement because they say 90 percent of their ranks will wither.
Fraud in home-health care is also a problem. In a December report, Medicare said firms have taken advantage of formulas that pay them up to $6,000 a month to see patients who need extra nurse visits, typically diabetics requiring two shots of insulin a day but who can’t inject themselves. Firms make $1,250 per month for three visits a week, a typical schedule.
Many new firms began billing for phony patients, the report said. Some firms classified diabetics who gave themselves injections as needing multiple daily visits. Others enlisted well clients to sign up for service by paying bribes or having nurses do their household chores.
In 2008, firms in Miami-Dade County collected $500 million in claims for patients who need more than one visit a day, half of what was paid in the nation for such patients. Miami now has 600 home care firms, compared with 95 in Broward and 71 in Palm Beach.
Franco said the abuse has spread to Broward, one of 23 counties now under review for excessive billings for costly patients. Nationally, 7 percent of home health patients needed more than one nurse visit a day. In Dade, it was 59 percent; in Broward, 19 percent.
Medicare’s solution: 40 firms were suspended in Miami-Dade. As of Jan. 1, patients who need multiple daily visits cannot exceed 10 percent of a firm’s billings to Medicare. Any above that would be paid at regular rates.
Some firms have been hit hard. Kevin Phillips, chief executive of The Nurses Guild, said he loses money on patients who need multiple daily visits and had to cut daily pay for his nurses, including Jacobson, to $15 from $50.
But the abuse is so well documented that the home health industry backs the cap.
“Fraudulent providers … have abused this loophole,” said Margery Harvey-Griffith, vice president at Boca Home Care.
Bob LaMendola can be reached at blamendola@SunSentinel.com or 954-356-4526.