Posted by: Robert Markette
February 25, 2008
Topic: Fraud and Abuse, Self Referral, False Claims

Tri Centurion has announced that it is going to start automatically denying certain plans of care in central Florida.  According to an article in this week's edition of Home Health Line, this is a response to the rise in  aide visits which Tri-Centurion termed wholesale abuse.  The article stated that patients were receiving in excess of three aide visits a week.  Apparently, in some case patients are routinely receiving multiple visits per day.  Of course, Tri-Centurion's response is to simply deny any claim, rather than evaluate every case to determine if a request is medically necessary.

I am not going to comment on the merits of Tri-Centurion decision, but I mention this case, because it raises another question for me.  According to the report, many agencies in Miami and surrounding counties offer excessive numbers of aide vists because patients demand them.  Agencies, in an effort to get the cases, will provide them to the patient.  This of course means agencies are providing unnecessary homecare visits in order to secure patients.  Nothing like a little fraud to improve your marketing results.  (Until OIG shows up and starts asking pointe questions.)

Tri-Centurion stated that aides are being used as "marketing tools" in other words, an inducement to choose a particular provider.  It seems like this practice should have been obviously problematic, but yet it was rather prevalent in Miami, which has had its share of fraud and abuse issue lately. Everyone is focused on the automatic denial issue, but I think that, given what went on, an OIG investigation does not seem far behind.

I can't help but wonder if this is a case of some agencies having success and not getting in trouble and others following suit, the classic "everyone else is doing it so why don't we". (Insert reference to the Cranberries here, not the vegetable, the rock band.)  Of course, that is not going to be of much help to providers when they start getting audited or worse.  Just because everyone else is doing it doesn't mean you won't get prosecuted.  The fact that the abuse became so widespread simply means everyone else was doing it guarantees it will come to the regulators' attention. 

 The way the regulators responded in this case brings up one other point, the government's response to fraud almost always makes it more difficult for everybody to provide care.  In this case, patients that legitimately need three or more visits a week will not receive them without additional efforts by the provider.  This creates more work for the providers who did not engage in the conduct.  Perhaps, rather than a denial policy, there should have been some other enforcement action.  Why punish everyone, even those who didn't do anything wrong?

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