Economic Business Impact

In the Medicare and Medicaid programs, the loss of financial resources will affect patients who actually need the care. This is a direct hit to the taxpayers who fund these programs and the patients who are covered by these providers. The data set highlighted significant anomalies that, projected with respect to claim data, were not plausible. The data in Exhibit 6.2 illustrates the volume being generated from one physician. The billed and claim amounts for one physician clearly exceed what is physically possible to achieve.

Exhibit 6.2 Claims Data

nc06f002.eps

Once a pattern has been identified, several approaches may be considered in obtaining a monetary impact on the claims submitted. First, the assumption that the doctor did, in fact, provide home health visits, and a volume that would be more plausible:

Assumptions:

  • The doctor worked five days per week and, geographically, could provide home health visits in the morning and facility-based visits in the afternoon.
  • Five hours per day for home health visits—five in one morning, maximum, for travel movement and documentation. Each visit is classified as a level three visit at $120.
  • Ten facility-based patients in one facility in one afternoon at two patients per hour. Each visit is classified as a level two visit at $75.

Although this assumption provides the benefit of the doubt for no breaks during the day by the ...

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