Home health fraud could be reduced by Knox doctor's patent
Cortney RoarkKNOXVILLE, TENN. - Nearly $3.6 billion in personal care services were paid improperly in 2015, as estimated by the U.S. Department of Health and Human Services. The amount is $1.6 billion more than that of 2014.
Dr. Ed Breazeale, founder and CEO of HealthStar LLC, has worked to decrease the amount of money paid improperly in the home health industry for nearly a decade.
Now, Breazeale holds a patent issued by the United States Patent and Trademark Office for the Electronic Visit Verification technology he designed to reduce fraud, waste and abuse in Medicaid reimbursement for home health services using GPS.
Within the first few months in use, the technology flagged a care giver attempting to bill services from Egypt while visiting family.
"In the outpatient world, nobody’s watching. It's that caregiver, that provider, driving around in a car, and they’re supposed to give grandma or granddad or aunt or uncle a certain amount of care," Breazeale said. "The question is, 'Does that care get delivered or not? How much time did they spend?' ... If you're cheating the patient or you're not doing what you're supposed to do, you’re not only cheating the patient but you're cheating the system."
The $3.6 billion estimated to have been lost in 2015 is an estimated number because of the lack of real-time verification of home health service delivery. Many times, a "pay and chase" method was used, Breazeale said. In other words, an audit was conducted after services were claimed and verified, primarily on paper.
HealthStar's EVV technology, launched two years ago in Tennessee, eliminates the pay and chase method through the use of GPS.
How HealthStar Visit works
When a provider arrives at each patient's home, he or she checks in on the device confirming the provider is at the correct location.
The software contains the patient's care plan, with prescribed services listed individually. Each service has a time frame assigned to it to ensure the provider does not skip a service.
Once the care plan is complete, the provider checks out and a claim is created. If a care plan was supposed to have taken the provider three hours, and the provider attempts to file a claim after one hour, the claim will be rejected.
The GPS technology stops providers from attempting to leave the residence and check off services elsewhere.
"We have documented cases where, for example, a care giver would check in at a patient's home and then the claim got kicked out, because the check-out did not meet the criteria," Krista Pelensky, VP of operations, said. "You can look and see that the check-outs were across the river in Memphis at the casino."
Not all instances of fraud seem as extreme. Breazeale has found multiple cases were providers would round up from 45 minutes to one hour, which adds up.
How does this play into the 21st Century Cures Act?
The 21st Century Cures Act was signed into law in December 2016 by President Barack Obama. It includes provisions that require the use of EVV technology for all Medicaid-provided personal care services and home health services by Jan. 1, 2019. If a state fails to implement EVV it will face a tiered reduction in Federal Medical Assistance Percentages funding.
"It's got all our points in there but one thing is missing – GPS," Breazeale said. "We’re working to get GPS in the rules. Real time GPS, because we know that is the only way to differentiate what's really happening. That is the best practice."
The HealthStar Visit platform was constructed for the State of Tennessee's set of EVV requirements. The platform's modular design allows it to be changed to accommodate other state and health plan differences.