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Fraud by Home Health Care Workers and the Criminal Justice Response

NCJ Number
Criminal Justice Review Volume: 26 Issue: 2 Dated: Autumn 2001 Pages: 209-232
Brian K. Payne; Charles Gray
Date Published
24 pages
This article describes the investigation of fraud in the home health care field.
With the increased use of home health care, caused partly by the growing number of older persons in the United States, the number of violations occurring in the home health care system has increased significantly. Though fraud is known to occur in both Medicare and Medicaid systems, this article focuses on fraud in the Medicaid system. Medicaid reimbursements are based on a shared fiscal responsibility between Federal and State governments, with the Federal government providing a significant proportion of the monies to be used to administer the Medicaid programs at the State level. There are several types of Medicaid fraud, including fee for service reimbursement, upgrading, pingponging (referring to other providers for unnecessary treatment), kickbacks, ganging (billing for several individuals when services were for one patient), double billing, and unbundling (billing for each medical test separately). Research shows that psychiatrists and psychologists are over-represented in allegations of fraud, in part because they bill for time rather than for medical services. An estimated 10 to 40 percent of the health care budget is being lost to fraud. The authors analyzed data from 247 cases of home health care fraud originating from the Medicaid Fraud Report. Results show that a variety of home health care professionals engage in an assortment of fraud and that the fraud control units seem to use traditional policing strategies to detect and investigate home health care fraud. The process for prosecuting and sentencing home health care offenders is quite similar to the process for handling other offenders. Among the policy implications arising from this study are: (1) officials must not assume that all health care frauds with the same label have the same consequences; (2) inmate services should be re-considered due to the high number of home health care offenders sent to jail; and (3) community service seems to be a useful and appropriate sanction for many types of offenders. 3 tables, 77 references