Source: https://www.lilesparker.com/category/medicare-overpayments/
Timestamp: 2019-05-21 14:30:39
Document Index: 517771782

Matched Legal Cases: ['§ 1001', '§ 1035', '§ 1347', '§ 1518', '§ 1320', '§ 1862']

Any person wishing a free consultation in the area should contact Michael Cook, the author and Co-chair of our Health Care Group. Michael can be reached at (202) 298-8750 or mcook@lilesparker.com.
January 9, 2019 by Robert Liles
(January 9, 2019): Despite real progress being made with respect to regulatory compliance, home health agencies, their owners, and affiliated health care professionals (such as referring / supervising physicians, therapists and staff) remain under strict government scrutiny. The government’s efforts to investigate and prosecute home health fraud cases have been especially evident in Texas. In calendar year 2018, a number of home health agencies, owners and affiliated individuals have been indicted, prosecuted and / or sentenced in connection with their improper conduct. This article examines many of these recent cases and discusses the improper conduct that led to these Texas home health prosecutions.
I. Texas Home Health Prosecutions in Calendar Year 2018:
Several significant home health fraud cases were investigated and prosecuted by the Department of Justice (DOJ) in Texas during 2018. These cases included, but were not limited to the following:
Southern District of Texas. December 2018. In this case, the owner of a home health agency allegedly paid marketers and group home owners for Medicare beneficiary information which he used to bill Medicare and Medicaid for home health services that were either not provided or did not qualify for coverage and payment. The government also alleged that the defendant owner “personally falsified home health patient assessment forms to make the beneficiaries appear sicker on paper to receive higher reimbursement rates from Medicare,”and that he instructed agency employees to falsify home health certifications and forge physician signatures. A jury found the defendant guilty and he was sentenced to 109 months in prison. The defendant was also ordered to pay $3.5 million in restitution to the Medicare program.
Northern District of Texas. October 2018. Two owners and the administrator of a home health agency were convicted in this prosecution of various health care fraud violations after a six-day trial. The owners were convicted of conspiracy to commit health care fraud, and one of the owners and the administrator were convicted of two counts of making a false statement in connection with a health care benefit program. At trial, evidence was presented that both of the home health agency owners had previously been excluded from participating in federal health benefit programs. The government alleged that the administrator concealed the fact that the home health agency owners were excluded parties. The government further alleged that the administrator signed false documents indicating that a third person was the owner of the agency and that no one associated with the home health agency had been excluded from participating in federal health benefits programs such as Medicare and Medicaid. Federal prosecutors were also able to show that the home health agency had billed the Medicare and Medicaid programs more than $3.7 million to which it was not entitled because the agency was owned by excluded parties. The defendants have not been sentenced as of the date of this publication.
Northern District of Texas. October 2018. In this case, a licensed vocational nurse who was also the part-owner of a home health agency was sentenced to 120 months in prison for her role in the fraudulent submission of home health claims to Medicare for payment. The former part-owner and supervising physician at a physician house call company was also sentenced to 42 months in prison for his role in the fraud. Two additional home health agency employees were also convicted for their roles in the fraud. At trial,the government produced evidence that the supervising physician certified the medical necessity of home health services for a number of patients who had never been seen,and that the physician billed Medicare for over $1.6 millionin medically unnecessary home health certifications and physician home visits.
Southern District of Texas. October 2018. A patient recruiter was sentenced to 108 months in prison today for her role in a $3.6 million home health Medicare fraud scheme in this health care fraud case. At trial, the government submitted evidence to prove that the defendant patient recruiter sold personal patient information to a home health agency which it then used to bill the Medicare and Medicaid program for services that were either not medically need or were never even provided. Notably, the patient recruiter paid Medicare beneficiaries, doctors, physical therapy companies and others for the paperwork and Medicare beneficiary information and services needed to facilitate the fraud. Finally, to hide the fraud, the patient recruiter tried to make it look like she was paid an hourly wage and the marketing services she was providing were legal and proper.
Southern District of Texas. June 2018. The part-owner of a home health agency, who also served as the agency’s Director of Nursing, was indicted in this prosecution for conspiracy to commit health care fraud. The government has alleged that the defendant, along with an unnamed group of co-conspirators, paid physicians to falsely certify the medical necessity of home health services for Medicare beneficiaries. The defendant and the unnamed group of conspirators are also charged with paying patient recruiters for referring Medicare patients to the home health agency. The government has also filed a criminal forfeiture count in the indictment in which it claims that more than $16 million is subject to forfeiture.
Southern District of Texas. June 2018. The owner of a Harris County home health agency was indicted by a Federal Grand Jury for Conspiracy to Defraud the United States, paying and Receiving Health Care Kickbacks, and substantive violations of the Federal Anti-Kickback Statute. Specifically, the government has alleged that the defendant owner and a number of co-conspirators paid kickbacks to several patient recruiters in exchange for referring Medicare beneficiaries to the owner’s home health agency. The government also alleges that the defendant owner and his co-conspirators paid kickbacks to a number of physicians in exchange for their certification of Medicare-required paperwork, and that they paid Medicare patients for their Medicare information in order to bill the Medicare program for home health services. The case is set for trial in 2019, and the government also has included a criminal forfeiture count in the indictment, seeking the forfeiture of at least $1.2 million
Eastern District of Texas. June 2018. In this case, the owner of a Missouri City, Texas home health agency, was indicted for conspiracy to violate the Federal Anti-Kickback Statute and f or violations of the Aiding and Abetting statutory requirements. The defendant and a co-conspirator patient recruiter are alleged to have paid cash amounts ranging from approximately $1,600 to $2,900 to Medicare beneficiaries to sign up for home health services with the defendant’s home health agency. The matter is set for trial later this year.
Southern District of Texas. May 2018. After a three-day trial, a Federal jury found a patient recruiter for a Texas home health agency guilty for her role in a $3.6 million Medicare fraud case. The patient recruiter was found guilty of one count of conspiracy to commit health care, five counts of health care fraud, and one count of conspiracy to pay health care kickbacks. At trial, evidence was introduced that showed that the defendant and her co-conspirators submitted claims to Medicare for home health services that were not medically necessary and, in some case, were not provided. According to the government, the patient recruiter “paid beneficiaries, doctors, physical therapy companies, and others for the paperwork, Medicare beneficiary information, and services needed to facilitate the fraud.”
Southern District of Texas. January 2018. In this final case, a Texas mayor (a licensed physician and Medical Director) and three owners of a number of home health and hospice providers services, were indicted for their roles in an alleged $150 million health care fraud and money laundering scheme. The government has alleged that the owners caused kickbacks and bribes to be paid to the defendant physician (and other physicians) who served as Medicare Directors for their home health agency in exchange for falsely certifying that Medicare patients qualified for services. The defendant owners are alleged to have fraudulently kept patients on hospice services for years when such care was not medically appropriate. A number of the defendants are also alleged to have made a false statement to the FBI and / or obstructed justice by producing false and fictitious records to a Federal Grand Jury.
II. What Lessons Can be Learned from these Home Health Prosecutions?
At the outset, it is important to note that none of the home health fraud prosecutions discussed above were based on differing professional assessments of the Medicare beneficiaries’ clinical condition or on a battle between medical experts over the medical necessity of home health services. Instead, Texas prosecutors focused on illegal payments in the form of kickbacks and bribes by home health owners and operators in exchange for the referral of Medicare patients, falsification of certifications or statements, and/or for acquisition of beneficiary information. In other words, the Federal criminal cases being brought against home health owners, operators and affiliated physicians were based on the parties’ fraudulent conduct, not on the quality of care provided or the medical necessity of the home health services. Several fundamental lessons to be learned based on these cases include:
Lesson #1: Sooner or later, improper Medicare claims practices and criminal wrongdoing WILL be identified by law enforcement or one of the contractors working for the Centers for Medicare and Medicaid Services (CMS).
Since first passing the Medicare and Medicaid programs in 1965, the government has been compiling utilization, coding, and billing data related to the services billed to Federal and State health benefit programs. CMS shares access to this information with a number of private claims processing and / or program integrity contractors.[1] These entities are required (as part of their contractual obligations to CMS), to conduct data mining analyses of provider and supplier coding, billing and utilization practices. While criminal conduct may escape discovery in the short run, it is essential for home health agencies, their owners, patient recruiters and affiliated physicians to recognize that there is a strong likelihood that the government will ultimately find out about the wrongdoing.
Lesson #2: Don’t pay kickbacks. . . ever. You will eventually be caught.
The Anti-Kickback Statute became a felony in 1977.[2] Under the Anti-Kickback Statute, it is a criminal violation to offer, pay, solicit or receive anything of value to induce referrals or generate referrals reimbursed by Federal health care programs.[3]The Department of Health and Humans Services, Office of Inspector General (OIG) first publicized the agency’s concerns regarding home health related kickbacks in a “1995 Special Fraud Alert.”[4] At that time, the OIG identified the following business practices as improper and potential violations of the Anti-Kickback Statute:
“Payment of a fee to a physician for each plan of care certified by the physician on behalf of the home health agency.
Disguising referral fees as salaries by paying referring physicians for services not rendered, or in excess of fair market value for services rendered.
Offering free services to beneficiaries, including transportation and meals, if they agree to switch home health providers.
Providing hospitals with discharge planners, home care coordinators, or home care liaisons in order to induce referrals.Providing free services, such as 24-hour nursing coverage to retirement homes or adult congregate living facilities in return for home health referrals.
Subcontracting with retirement homes or adult congregate living facilities for the provision of home health services to induce the facility to make referrals to the agency.”
Most of the Texas home health prosecutions pursued by DOJ prosecutors in 2018 involved illegal kickback conduct that the government first identified its 1995 Special Fraud Alert. Despite the fact that more than twenty years have elapsed, a number of home health agency owners, operators, marketing personnel and referring physicians have continued to engage in illegal kickback activities.
Lesson #3: Don’t play games. Efforts to deceive the government or obstruct an investigation will only compound your problems.
In the criminal cases outlined in Section II above, a number of the defendants engaged in deceitful conduct. Several examples of the deceitful conduct included:
“A home health agency owner was alleged to have falsified home health patient assessment forms.
A home health agency owner was alleged to have instructed home health staff to falsify physician signatures.
A home health agency administrator was alleged to have signed false documents indicating that a third-party owned the agency and that no excluded parties were associated with the agency, when in fact, the true owners had been excluded from participation in the Medicare program.
Defendants were also alleged to have made a false statement to the FBI and / or obstructed justice by producing false and fictitious records to a Federal Grand Jury.”
There are several Federal statutes that are implicated by this type of deceitful conduct.[5] Statutory provisions that may be implicated (depending on the facts), include, but are not limited to:
Fraud and False Statements (18 U.S.C. § 1001). It is illegal for any person, in connection with any matter before any branch of the federal government or any federal agency, to do any of the following: (1) falsify or conceal a material fact; (2) make any material misrepresentations; or (3) make or use any false document knowing that such document contains a material falsehood.
False Statements Involving Health Care Programs (18 U.S.C. § 1035). It is unlawful for any person to, in any matter involving a health care benefit program and in connection with the delivery of or payment for health care services, knowingly: (1) falsify or conceal a material fact; (2) make a material misrepresentation; or (3) use a document knowing that it contains a material misrepresentation.
Health Care Fraud (18 U.S.C. § 1347). It is unlawful for any person to knowingly: (1) defraud any health care benefit program; or (2) obtain by false pretenses any money or property owned or under the control of a health care benefit program.
Obstruction of a Criminal Investigation into Health Care Offenses (18 U.S.C. § 1518). It is unlawful to prevent, obstruct, or delay the communication of information relating to a federal health care offense to a criminal investigator.
False Statements Involving Federal Health Care Programs (42 U.S.C. § 1320a–7b(a)). It is unlawful for any person to: (1) knowingly make a false statement in an application for benefits or payment under a federal health care program; (2) knowingly make a false statement for use in determining rights to benefits or payment under a federal health care program; (3) knowingly conceals or fails to disclose any event affecting one’s eligibility for benefits or payment under a federal health care program; (4) knowingly use the benefits or payment of another under a federal health care program for some reason other than their intended purpose; (5) knowingly present a claim for a physician’s service under a federal health care program where the person presenting the claim knows the service provider was not a licensed physician; or (6) knowingly assist another in disposing or transferring of assets such that he or she will be eligible for benefits under a federal health care program.
Violations of these statutes are often uncovered during the course of administrative audits by CMS program integrity contractors. These types of violations may also arise in connection with patient complaints and whistleblower cases.
Lesson #4: Medical Director agreements — it all comes down to the nature of the business relationship.
Both parties need to recognize the importance of conducting due diligence before entering into a contract with a Medical Director. Does the home health agency have an effective Compliance Program in place? Has either the home health agency or the physician being considered for a Medical Director position been the subject of an adverse action by Medicare, Medicaid, or a private payor? To paraphrase the Greek philosopher Aesop, “You are judged by the company that you keep.”
When reviewing Medical Director agreements, government prosecutors and investigators are trained to conduct a critical assessment of these business relationships. Are the terms of the Medical Director agreement consistent with Fair Market Value principles? Has the Medical Director properly documented the services he or she provided and properly recorded the amount of time being spent in the performance of his or her Medical Director duties? How many patient referrals are generated by your Medical Directors? In a perfect world, a home health agency would not receive any patient referrals from the agency’s Medical Director. To the extent that an agency’s Medical Director does, in fact, make a significant number of referrals to the agency for home health services, the government will understandably wonder whether the referrals being made are in exchange, in whole or in part, for the monies being paid to the physician under the Medical Director agreement.
Lesson #5: Do you employ sales or marketing personnel? Regardless of whether you refer to a position as a Community Outreach Coordinator, a Marketing Specialist or a Physician Liaison, the government will still carefully review how these individuals are compensated, and the actual duties that are being performed.
Marketing activities that may constitute ordinary business courtesies if extended to an actual or potential referral source in another industry, are often illegal in the context of Federal health care programs. Home health agencies that employ or contract with individuals to conduct marketing services on behalf of the agency need to ensure that the services being performed do not violate the Federal Anti-Kickback Statute or, if applicable, a state’s bribery law or all-payor statute. Compensation agreements that reward a marketing individual based on the number of patient referrals generated are especially problematic.
The likelihood that your home health agency will be subjected to a Medicare or Medicaid audit or investigation increases every day. As a participating provider in one or more Federal health care programs, providers have an affirmative obligation to ensure that your claims are properly documented, coded, and billed. Additionally, providers must ensure that otherwise payable home health service claims have not been “tainted” by any statutory or regulatory violation of the Stark laws, the Federal Anti-Kickback Statute or the False Claims Act. When examining whether a claim is “payable,” a provider needs to remember that even though the medical service at issue may have been medically necessary and qualified for payment, if it is the result of an illegal activity, it will be tainted and will likely not qualify for payment. Unfortunately, many providers have never researched or reviewed the proper rules covering the work they provide. If you have questions? Give us a call. Liles Parker attorneys have extensive experience representing home health providers around the country in connection with Medicare audits and investigations.
Robert W. Liles, J.D., M.B.A., M.S., serves as Managing Partner at the health law firm Liles Parker, PLLC. Liles Parker attorneys represent home health and hospice agencies around the country in connection with Medicare and Medicaid audits and investigations of home health and hospice services. Has your agency received an administrative request or a subpoena for records? Give us a call. We can help. For a free consultation, please call: 1 (800) 475-1906.
[1] CMS works with claims processing contractors (Medicare Administrative Contractors (MACs)), and program integrity contractors (such as Recovery Audit Contractors (RACs), Supplemental Medical Review Contractors (SMRCs) and Uniform Program Integrity Contractors (UPICs) to identify overpayments and instances of potential fraud which may be referred to law enforcement authorities for investigation and prosecution.
[2] 42 U.S.C. 1320a-7b(b). The Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 (Public Law 95-142), made violations of the Anti-Kickback Statute a felony. It also made those who offered remuneration for referrals and those who received them subject to various penalties.
[3] Under 42 U.S.C. 1320a-7b(f),a “Federal health care program” is defined as:
“(1) any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government (other than the health insurance program under chapter 89 of title 5); or
(2) any State health care program, as defined in section 1320a-7(h) of this title.”
[4] Federal Register, August 10, 1996 (Volume 60, Number 154). A copy of this Special Fraud Alert can also be found on OIG’s website.
[5] For each of the criminal statutes identified below, there are corresponding regulations which would authorize the imposition of Civil Money Penalties by the Health and Human Services, Office of Inspector General (HHS/OIG), see, 42 U.S.C. 1320a-7a(a).
June 20, 2017 by Robert Liles
(June 20, 2017): As the Department of Health and Human Services (HHS), Office of Inspector General (OIG), signaled in both its 2016 and 2017 Work Plans, the government is concerned about the rapid growth they are seeing in the number of physician home services billed to the Medicare program. In order to qualify for coverage and payment, physicians providing this type of care are required to document why it is medically necessary to conduct a home visit of a patient in lieu of an office or outpatient visit. In light of the restrictive nature of these services, the OIG is in the process of conducting assessments of health care organizations that bill the Medicare program for Evaluation & Management (E/M) services provided at a beneficiary’s home, sometimes colloquially referred to as “house calls.”
I. CPT Codes Used to Bill E/M Home Services in a Patient’s Residence:
Only a limited set of codes may be used to report E/M services rendered to a patient living in their own home or apartment. CPT® codes 99341 through 99350 are used to code for Home Services. In order to qualify for coverage and payment under the Medicare program, the documentation must show that the E/M guidelines have been met and, in the case of a nonphysician practitioner (NPP), that the home service provided fits within the scope of practice authorized in that state. A description of these codes is outlined below. Please note, the time estimates indicated are only included in the AMA CPT Codebook descriptions. They are not included in either the 1995 or 1997 E/M Guidelines.
Home Visit Codes – New Patient:
99341 Low severity problem, 20 min.
99342 Moderate severity problem, 30 min.
99343 Moderate to high severity problem, 45 min.
99344 High severity problem, 60 min.
99345 Patient unstable or significant new problem requiring immediate physician attention, 75 min.
Home Visit Codes – Established Patient:
93347 Self-limited or minor problem, 15 min.
99348 Low to moderate problem, 25 min.
99349 Moderate to high problem, 40 min.
99350 Patient unstable or significant new problem requiring immediate physician attention, 60 min.
These codes cannot be used if the patient resides in a shared living facility or group home. In order for a home visit to be billed by a physician, the physician must have actually been present in the beneficiary’s home. These codes only apply in care settings that can be properly coded as Place of Service (POS) 12 (Patient’s Home).
II. Does a Patient Have to be “Homebound” in Order to Qualify for Home Services?
The homebound requirements of Medicare’s home health benefit are not applicable to the provision of home services (as billed under CPT codes 99341 through 99350). In other words, a Medicare beneficiary does not necessarily have to be “confined to the home” in order for a physician to provide a covered home visit. Nevertheless, the medical record must document why it was medically necessary for the physician or qualified NPP to conduct a home visit in lieu of seeing the patient in the physician’s office or in an outpatient clinic.
III. CMS Contractors are Actively Auditing E/M Services Conducted in a Patient’s Home:
It is important to note that in addition to OIG, several CMS contractors are also actively auditing providers that have billed Medicare for E/M services conducted in a patient’s home. As with their law enforcement counterparts, these administrative contractors are focusing their audits on whether the home visit was, in fact, medically necessary. As you will recall, a fundamental Medicare requirement under § 1862(a)(1)(A) of the Social Security Act is that:
“. . . no payment may be made under part A or part B for any expenses incurred for items or services —
(1)(A) which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. . .”
With only limited exceptions,[1] the services provided by a physician or an NPP cannot be services that could be provided by a visiting nurse or home health agency under Medicare’s home health benefits program.
Additionally, the decision to provide home visit services must be based on the medical necessity of providing in-home care. Medicare auditors will review the patient’s medical records carefully to determine if, in fact, the patient was unable to come to the physician’s office or an outpatient clinic for care. Moreover, even if the documentation supports that the patient was unable to come the physician’s office or outpatient clinic on a specific date due to physical or mental disabilities, if the documentation does not support additional in-home visits, they will be denied.
IV. Know the Coverage Rules and Check Your LCD Covering Home Services:
It is essential that you understand the coverage and billing requirements governing home services as set out in the Medicare Benefit Policy Manual (MBPM) and the Local Coverage Determination (LCD) issued by your Medicare Administrative Contractor (MAC). LCD requirements may slightly vary from one jurisdiction to another. Therefore, you need to ensure that your practices fully comply with the LCD requirements applicable to your claims.
When assessing whether one or more home services are medically necessary, Medicare auditors will carefully examine the documentation associated with each visit. The documentation of each beneficiary encounter must include:
Physical examination findings, and prior diagnostic test results, if applicable;
Medical plan of care including how the visit will change/changed the care of the beneficiary.
To be clear, a physician or NPP must also obtain a full range of the administrative information normally obtained in an office visit when visiting a new patient. For instance:
Did you provide the patient with necessary HIPAA privacy information? Did the patient complete a “Notice of Privacy Practices” form
Have you obtained an executed “Consent for Treatment” form from the patient?
Did you obtain a completed intake form for use with new patients?
Did you have the patient complete a form outlining their prior medical, family and social history?
Did you provide a copy of the organization’s financial policies to the patient?
V. Risk Areas When Billing for Home Services:
If audited, the Medicare reviewer examining your claims will likely deny payment if one of the following reasons for denial is identified:
It appears that one or more of the home services were was conducted for the convenience of the patient, the patient’s family, or the physician, AND the documentation does not reflect that the patient was unable to come to the physician’s office or an outpatient clinic for care.
The medical record does not clearly demonstrate that the patient, his/her family or another clinician involved in the case sought the initial service. In other words, what was the source of this referral? Was the care solicited by a party representing the home visit organization?
The home services are provided at a frequency that exceeds that which is typically provided in the office and acceptable standards of medical practice.
The home services are not being personally performed by a physician. It is being performed by an NPP but the claim is being billed at the physician’s rate.
The home services are being solely performed by an NPP but only the physician, not the treating NPP, is credentialed with Medicare.
The specific services provided during the home services could be provided by a visiting nurse or home health agency.
Home services (CPT® codes 99341 through 99350) billed to Medicare are currently being audited by multiple CMS contractors around the country and by OIG. If you receive a request for medical records from a UPIC, ZPIC or MAC, we recommend that you contact a qualified health lawyer as soon as possible. Depending on the contractor, the records request you receive may be related to a probe audit OR it may require that you send in a larger sample of records, one that the contractor contends is a “statistically relevant sample.” If that is the case, the contractor will likely seek to extrapolate the error rate found when it reviews your claims records. It is imperative that you understand the ramifications of such an audit – call your health lawyer immediately.
Robert W. Liles, J.D., M.B.A., M.S., serves as Managing Partner at the health law firm Liles Parker, PLLC. Liles Parker attorneys represent health care providers around the country in connection with Medicare, Medicaid and Private Payor audits. For a free consultation, please call: 1 (800) 475-1906.
[1] The Medicare Benefit Policy Manual (MBPM), Sec. 60.4, “Services Incident to a Physician’s Service to Homebound Patients Under General Physician Supervision,” outlines very limited circumstances when a physician can provide services that would normally be performed by a home health agency. Should a UPIC, ZPIC or MAC conduct a postpayment audit of these services, their review will focus, in part, on whether a “substantial number of the services provided under this coverage when they could otherwise have been performed by a home health agency.”
March 29, 2017 by Robert Liles
(March 29, 2017): The Centers for Medicare and Medicaid Services (CMS) has recently published a new Final Rule that makes changes to the Conditions of Participation for home health agencies. Under the Final Rule, providers are required to ensure that individuals and entities providing services under arrangement are not excluded, terminated, or debarred from any Federal health care program. Simply put, these new requirements are an affirmative obligation to screen both the Federal and State exclusion lists.
While CMS does not provide detailed guidance on how a home health agency is supposed to meet this new requirement, it does make it clear that the responsibility of properly screening contracted entities remains with the home health agency. Additionally, it makes no mention of how a provider could screen for a Medicaid exclusion. This lack of clarity on how to effectively meet this Condition of Participation could be problematic since CMS may now hold a home health agency liable for failing to catch a Medicaid exclusion. Home health agencies are cautioned to ensure that they are meeting their exclusion screening obligation / OIG screening obligation in order to avoid having their participation in Medicare terminated. What should your home health agency do? As a start, we recommend that you review the detailed discussion on this new requirement written by Paul Weidenfeld, Esq. at www.exclusionscreening.com.
Do you have questions regarding your exclusion screening obligations / OIG screening obligations? Give us a call. Liles Parker attorneys represent home health agencies around the country in connection with ZPIC audits, OIG investigations, exclusion issues, False Claims Act cases and transactional matters. Please call Robert W. Liles for a free consultation. He can be reached at: 1 (800) 475-1906.
CMS has recently announced that the Pre-Claim Review Demonstration Project will be resumed and that it will be implemented in Florida on April 1, 2017. While no implementation dates have been announced yet for Texas and the remaining test states, Texas home health providers could conceivably be facing this program as early as May 1, 2017.
In addition to providing an overview of the home health Pre-Claim Review Demonstration Project, this article examines the primary reasons for claims denial identified so far by Illinois home health agencies. In this first article, we are focusing on the denial reasons associated with errors identified with face-to-face and plans of care / certification / recertification documentation.
Robert W. Liles, M.B.A., M.S., J.D., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Liles Parker is a boutique health law firm, with offices in Washington DC, Houston TX, San Antonio TX, McAllen TX and Baton Rouge LA. Robert represents home health agencies around the country in connection with Medicare audits and compliance matters. Our firm also represents health care providers in connection with federal and state regulatory reviews and investigations. For a free consultation, call Robert at: 1 (800) 475-1906.
(November 23, 2016): The Office of Audit Services, Office of Inspector General (OAS), is in the process of conducting audits of large home health agencies. These audits are being conducted, in part, because the Centers for Medicare and Medicaid Services (CMS) had determined through the Comprehensive Error Rate Testing Program (CERT) that for 2014, there was greater than a 50% error rate nationally in Medicare claims for home health services. Additionally, it is our belief that because the advent of alternative payment methodologies is likely to diminish the relevance of the current process for medical necessity audits in the future, home health agencies are likely to experience a spike in audits of Medicare claims in the near future.
I. Initial Results From Early OIG Home Health Audits:
Irrespective of the motivation behind the audits, the first two audit reports resulted in findings of large error rates with extraordinary recommended refunds of more than $15 million for one agency and more than $8 million for the other. These results were generated by the application of a statistical extrapolation and a recommendation that the results be applied with an attendant request for refunds, not only for the three-year look-back period, but also for earlier years as a result of the “60 day” repayment rule. See Medicare Compliance Review of Excellent Home Care Services, LLC, Report No. A-02-14-01005 (OAS, July 2016); Medicare Compliance Review of Home Health VNA for 2011 and 2012, Report No. A-01-13-00518 (August 2016).
As a result, we are aware of several companies that are now undergoing similar types of audits by OAS. The review of these claims has been subcontracted to Maximus, a Qualified Independent Contractor (“QIC”) with experience in reviewing medical necessity audit determinations.
In the past for claim audits by MACs or ZPICs, clients would frequently submit the medical records without preparing any claim summaries, and instead prepare those summaries for purposes of the appeals process after the initial findings.
Because of the extraordinary refunds that have been recommended by the OAS reports cited, above, coupled with the significant delay in obtaining ALJ hearings after refunds are required, providers that receive notices of these audits may wish to take a more proactive approach to defend the legitimacy of the claims under review, including retaining and working with legal counsel at the beginning stage of this process.
II. What is OIG Requesting in These Home Health Audits?
Specifically, providers undergoing these audits of which we are aware have been asked to submit the medical records for 100 claims. For each of these claims, providers should bates label the pages of the claim. Additionally, they should organize the records so that it is easy to track the various components of the adverse findings of the earlier audit reports, such as face-to-face, nursing, therapy, etc. Finally, they may wish to consider submitting detailed claim summaries that identify how each of the claims meets the various criteria for coverage and payment, that cite to specific pages of the medical record and that are submitted at the time that the client initially submits the medical record. Additionally, to the extent that the initial review discloses gaps or ambiguities that can be appropriately and legitimately supplemented or explained, agencies may wish to accomplish that process up front, rather than risking the potential of adverse findings that might not otherwise accurately reflect the claims. By responding proactively, providers may be able to minimize the likelihood of recommended denials based upon misunderstandings by the reviewers.
Given the magnitude of the findings and recommendations for refunds in the two audit reports published to date, we strongly recommend that providers who are notified that they are to undergo these audits contact legal counsel familiar with responding to audits at the initial stage, rather than waiting for the initial recommendations or draft audit report. Knowledgeable legal counsel familiar with the audit process and the types of individuals conducting the audit, can work effectively with the clinical team to present the records to the audit team in a manner that provides an accurate picture of the claim at the beginning stage, and by doing so, potentially minimize or avoid improper adverse findings prior to the issuance of the audit report .
Michael Cook is the co-chair of Liles Parker’s health care group and has more than 35 years of experience representing providers in regulatory matters, including matters of this nature. Before entering private practice, Michael also represented the Federal regulators of the Medicare and Medicaid programs, is a member of the Board of Medical Assistance Services in Virginia, and has advised the campaigns of a number of candidates for state and federal office. Any entity experiencing an audit of this nature or having questions can contact Michael at (202) 298-8750 or mcook@lilesparker.com.