Fraud Is Local. The Freeze Is Nationwide.

Jennifer Sheets (0:00)

If you work in care at home, you have probably felt the impact of fraudulent actors that has nothing to do with you. Outlier bad actors committed fraud, and the response landed on every honest provider in the country. Recently, CMS did something we warned them not to do. They hit pause on new home health and hospice enrollment nationwide for at least six months. And that's just one of three policy fights happening right now that care at home providers need to be watching. If we get these key policy decisions wrong, patients in communities that already cannot find a provider lose access entirely, while the providers doing it right get penalized for showing up. But here's the good news. None of this is settled, and we are not powerless. We have a clear message and a real seat at the table. So today, I am walking you through exactly where we stand on the policy landscape, the moratorium, and what we're telling CMS. So let's get to it.

So I'm very excited to have a special guest with us for this portion of our Coming Home Podcast. So Patrick Harrison is here with us from our Policy and Advocacy team. Thank you so much for being with us today.

I really want to unpack a couple of things around program integrity. Program integrity has become so central in the conversations that we're having, in the advocacy work that we're doing. Can you help us understand why this has become such a critical issue?

Patrick Harrison (1:44)

Absolutely, Jennifer. When we think of program integrity, when we think of the value that home health, hospice, Medicare, home and community-based services provide, it's absolutely critical that individuals who depend on these services can receive that without harm. To that end, any fraudulent activity absolutely cannot be tolerated. It's absolutely critical. We've stopped that. It's a threat to patients. It's a threat to individuals. It's also a threat to providers who are delivering quality care. In a way, in a manner, that's good faith.

Fraud hurts everyone.

Jennifer Sheets (2:27)

Absolutely. Absolutely. So, you know, I know we have brought forth some real solutions around how we can enhance program integrity, go after the bad guys, root out the fraudulent providers, without impacting compliant providers. Can you elaborate a little bit on some of the solutions that we could offer?

Patrick Harrison (2:46)

Certainly. Just as a threshold matter, when we're trying to tackle this problem, I've often used the sledgehammer analogy. Sledgehammer is, of course, when you smash bad actors, you want to ensure that you're not catching good actors in a fallout. And the vast majority of providers out there are operating in good faith. So to that end, we would support efforts to really use a bit of a scalpel approach, to make sure we are rooting out that fraud.

Some examples might include pre-payment review or a pre-claim review that help to ensure that services deliver, that are billed for in claims, are actually medically necessary and clinically appropriate. There's also the concept of gold carding. Providers who demonstrate continued efforts in good faith, continued compliance, we want to incentivize and ensure that that type of behavior can continue without penalizing them, without impairing their ability to continue serving their communities and the patients who ultimately depend on their services.

Jennifer Sheets (3:55)

There's also a difference in no date at a physician's signature, right? That's not fraud. That's a technical error. And when we talk about fraud, we're talking about patients that were never served, right? They don't even know they're under some of these benefits. Can you help listeners understand what we mean about fraud, waste, and abuse and how it differs from compliant providers in the care that's being provided?

Patrick Harrison (4:21)

This is a great question, and it's gotten a lot of attention at the federal level. And often there tends to be confusion about what these actually mean.

From the first and foremost, the fraud. We all know fraud is harms patients, harms beneficiaries, harms providers. And this generally involves willful intent to defraud the program, such as submitting claims for services that were never actually provided. Patients often have no idea that claims were built on their behalf for a service they never received. We have seen this in a number of areas. We've seen this as one of our benefits, which again harms individuals who depend on those services.

Waste is a little bit different. Waste is what really involves the overutilization or the inefficient use of resources. It may, it's not fraudulent. It may even be well intentioned. But this, it can be, perhaps you're billing for services that weren't excess of what actually the patient needed. But nonetheless, maybe you thought would help the patient. It can also be going above and beyond, again, what may actually even help the patient, but it's overutilization results in overspending to the Medicare or Medicaid program. And then you have abuse. And these generally involve practices that are inconsistent with fiscal, with business or medical standards that don't quite rise the level of fraud, they don't quite have that level of intent, but can result in a misuse of resources. One thing I want to distinguish here is we've often seen through this talk about program integrity, again, this confusion between fraud, waste and abuse.