Home Health Care Fraud

* Re “Fraud in Home Health Care Demands a Crackdown,” editorial, Aug. 3:

So 40% of federally financed home health care visits are either fraudulent or unnecessary (which is also fraudulent). The perpetrators of this fraud are the entrepreneurs of private industry who are generally believed to do everything better than any government agency. The government, at its worst, would do better than that. Other nations, virtually all in Europe, provide such services to their citizens and have nothing comparable in fraudulent claims, perhaps because they do not contract the administration of their programs to private enterprise.

The advantages of private enterprise are found in its motivation to invent, modernize, expand and improve. When we allow it to profit, unencumbered by government control, the result is virtually always a high level of fraud. When government does all of the work itself, the same result usually occurs. What is needed is government oversight of private industry to minimize opportunity to defraud and maximize availability of benefits to those who truly need them.

We have grown to hate the very word, but as this example makes clear, bureaucracy develops to control man’s greed and is an essential part of any government program.

PATRICIA A. FYLER

Brea

* In Southern California, we note the fastest growing segment of the population is persons over 80. Physicians in L.A. County direct their patients to appropriate home care in lieu of costly hospital stays. The Health Care Finance Administration itself has spent many of our tax dollars on the education of the Medicare beneficiaries to inform them of their right to home health care. At a minimum, one should note the population and severity-of-illness statistics that are influencing the increase in expenditures.

Since October 1996, Medicare home health care recipients have been receiving a letter of explanation of benefits that urges them to check that the number and type of services they have received are the same as the number for which a claim has been submitted. The fiscal intermediaries track and resolve all inquiries.

The GAO report categorized visits as “ . . . or unnecessary.” This phrase refers to a determination after the fact that clinical care given was not medically necessary. HCFA’s own data indicate that this is a mere 0.2%. The medical necessity of the patient’s care is determined by the physician, not the home heath care provider acting in a vacuum.

Locally and statewide, the majority of home care providers have been urging HCFA and the California Department of Health Services, Division of Licensure and Certification to require owner/operator screens for all new entrants to Medicare home care, and more importantly, to require some type of knowledge competency to better qualify the potential providers. We are in full agreement with the just application of civil and monetary fines in accordance with the principles of due process and in compliance with federal regulations.

MARY K. DETE, President

Home Health Council of

Los Angeles