Most healthcare providers are honest and operate legitimate businesses. Yet news reports surrounding fraud cases tell us some are not.

It is clear the U.S. federal government is serious about cracking down on fraud. In fiscal year 2013, the government’s healthcare fraud prevention and enforcement efforts recovered a record-breaking $4.3 billion in taxpayer dollars, up from $4.2 billion in fiscal year 2012, from individuals and companies who attempted to defraud federal health programs serving seniors or who sought payments from taxpayers to which they were not entitled, according to the U.S. Department of Health & Human Services.

Take, for instance, the following examples of recent court cases:

• In Florida, three individuals were indicted for allegedly defrauding Medicare and Medicaid for $2.4 million in a home health scheme involving false prescriptions and plans of care.
• The operator of a Louisiana home care agency and 20 individuals were indicted for their alleged role in a $30 million Medicare fraud case. Doctors allegedly signed orders and plans of care for beneficiaries who had no legitimate medical necessity for the services.
• In Detroit, two individuals were convicted for fraudulent activities that garnered $1.6 million from Medicare. The individuals allegedly fabricated patients’ medical records to make it appear that they qualified for and received home health services, which they did not.

What can home health agency owners do to protect their businesses and reputation from unscrupulous employees?

• Conduct thorough background checks. Include a criminal screening of each employee. Financial background checks should be performed for billers and administrators. Although the federal government does not require that home health agencies conduct background checks of employees, agencies must comply with state laws. Also, be sure to verify nursing licensure through the state’s Board of Nursing.
• Follow patient referral requirements. Ensure that patient referrals are thoroughly verified with solid documentation on the need for home health services. It is better to refuse a patient than accept a questionable referral. An in-person assessment should be performed by a trusted agency professional.
• Practice meticulous billing. Billers  need to be careful to not mark orders as received when they do not have a physician-signed copy in hand and to not bypass orders when they have not all been received.
• Understand proper coding. Coders need to be well-versed in coding requirements. Be on the look-out for up-coding to bill for higher reimbursements than permitted. Require clinicians to document thoroughly, especially for the OASIS assessment and reassessments. It is better to over document than under document. Match each visit note to the plan of care to verify that services are provided as planned.
• Use Electronic Visit Verification (EVV). Agencies should equip clinicians with an EVV app on a mobile device such as a SmartPhone or tablet to document that the clinician actually delivered care at the point of care (patient’s home). An EVV app captures the GPS location and date and time stamps the record when the clinician checks-in and checks-out for the visit. The patient’s electronic signature is also captured to document the visit took place.

As the federal government continues to uncover instances of healthcare fraud nearly daily, business operators need to safeguard themselves from the possibility of fraudulent activity within their organizations. Quality assurance measures such as those above are good first steps in fraud prevention.