In recent years, the US has seen a sharp increase in fraudulent billing by Home Health Agencies (HHAs) to Medicare.
To better understand this trend, researchers from Dartmouth’s Geisel School of Medicine conducted a study that provides new insights into how such fraudulent practices spread across the country.
The study’s findings were published in the journal Social Science & Medicine.
HHAs primarily provide skilled nursing and other medical services to patients at home, with over 11,000 such agencies serving Medicare beneficiaries across the US.
However, several instances of fraud have been documented, ranging from billing for unnecessary or non-existent services to illegal kickbacks to physicians for patient referrals.
The study identified certain common characteristics in regions where fraud was more likely.
These included the sharing of patients across multiple agencies, high rates of expenditures, and rapid increases in the number of HHAs.
Interestingly, these regions were also the ones that typically attracted Department of Justice (DOJ) anti-fraud offices.
To facilitate their research, the team developed a new tool called a bipartite mixture (BMIX) index.
It measures the links between each patient and each HHA, providing a deeper understanding of the diffusion process than conventional network measures.
Data from the Dartmouth Atlas of Health Care revealed a dramatic increase in home health care activity from 2002 to 2009, with expenditures more than doubling from $14.9 billion to $33.7 billion.
However, this increase was concentrated in just a few regions, like McAllen, TX, and Miami, FL.
The researchers also developed an economic model to explain why fraudulent behavior expanded rapidly in certain healthcare markets but not others.
The model suggests that fraud is more likely when perpetrators perceive the benefits as exceeding the risks.
The BMIX index has shown promise in predicting future excessive billing behavior, indicating its potential usefulness in machine learning approaches to identify Medicare fraud in HHAs.
Lead author James O’Malley hopes that their methods could be used by organizations policing the healthcare system, allowing for earlier prosecution of violators and potentially saving US taxpayers a significant amount of money.
As O’Malley concludes, this study was a joint effort with important contributions from his two co-authors: Jon Skinner, a health economist, and Tom Buboltz, a recently retired veteran of The Dartmouth Institute who has worked with Medicare claims data throughout his career.
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The study was published in Social Science & Medicine.
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