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October 5, 2012

OIG Work Plan 2013

On October 3, 2012, the OIG released its Work Plan for the FY of 2013. Throughout the week, we will be posting on various aspects of the Work Plan pertinent to our clients and our readers in the following areas:

• Hospitals
• Home Health Agencies
• Hospices
• Evaluation and Management Services
• Imaging Services
• Diagnostic Testing
• Sleep Testing
• Medical Equipment and Supplies
• Medicare Audits and the Appeals Processes

Check back every day for updates!

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September 28, 2011

Medicare Fraud Indictment Results in More Guilty Pleas in $25 Million Health Care Fraud Scheme

In a press release issued September 27, 2011, the United States Department of Justice, the Department of Health and Human Services, and the FBI announced that two Miami-area residents pled guilty for their roles in a $25 million home health Medicare fraud scheme. Both defendants pled guilty to conspiracy to commit health care fraud, which carries a maximum prison sentence of 10 years.

Maritza Vidal and Richard Diaz admitted their participation in a scheme to bill Medicare for expensive physical therapy and home health care services that were prescribed by doctors but were medically unnecessary and never provided. According to court documents, Vidal and Diaz worked for ABC Home Health Inc. or Florida Home Health Providers Inc., two related Miami home health care agencies, which purported to provide home health and therapy services to Medicare beneficiaries, but allegedly existed only to defraud Medicare.

Vidal and Diaz both admitted to recruiting Medicare beneficiaries who would allow ABC and Florida Home Health to bill Medicare for home health care and therapy services that were medically unnecessary and/or never provided. The defendants also solicited and received kickbacks and bribes from the owners and operators of the home health agencies in return for allowing the companies to bill on behalf of the recruited patients.

Vidal also admitted that she and other co-defendant nurses falsified patient files for Medicare beneficiaries by describing non-existent symptoms such as tremors, impaired vision, weak grip and inability to walk without assistance in an attempt to make it appear that the patients qualified for home health benefits.

Vidal and Diaz were originally charged in a February 2011 indictment, which included numerous other defendants. Including Vidal and Diaz, seventeen people have pled guilty for their roles in the fraud scheme.

This case was investigated by the FBI and HHS-OIG, and was brought as part of the Medicare Fraud Strike Force. Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,140 individuals who collectively have falsely billed the Medicare program for more than $2.9 billion.

These recently announced guilty pleas bear out the advice that we have been delivering to clients, namely that the health care enforcement landscape is evolving and thus it is even more imperative to ensure that providers take pro-active steps to mitigate the likelihood that they will become subjects of the government's more robust initiatives to prevent health care fraud

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September 2, 2011

Metro Detroit Continues to be a Focus of Health Care Fraud Prosecutions

On September 1, 2011, the Department of Justice, the Department of Health and Human Services (HHS), the FBI and the HHS Office of Inspector General (HHS-OIG) jointly announced that eighteen individuals have been charged in the Eastern District of Michigan for their participation in a series of separate Medicare fraud schemes involving home health and psychotherapy services.

According to the court documents, the schemes allegedly involved a total of more than $28 million in fraudulent claims submitted to Medicare for services that were medically unnecessary and/or never provided.

Fourteen individuals are charged in one indictment with conspiracy to commit health care fraud for their roles in a $14 million scheme to defraud Medicare by submitting fraudulent claims for home health care services. The defendants include three physicians, four clinic owners and managers, two clinic employees, one nurse, and four physical therapists and physical therapy assistants. As alleged, the conspiracy was operated out of multiple home health agencies located in Livonia.

In a separate complaint, a physician and two other individuals are charged with health care fraud and the submission of false claims in connection with an approximately $11.5 million scheme to defraud the Medicare program. The scheme allegedly involved false billings for individual and group psychotherapy services at two clinics located in Detroit. According to court documents, the defendants billed Medicare for services that were medically unnecessary and/or never provided.

In another indictment, the owner of a medical clinic located in Southfield was charged with conspiracy to commit health care fraud, health care fraud and identity theft for a scheme allegedly involving $2.9 million in fraudulent billings to Medicare. The clinic owner is alleged to have used the identities of Medicare providers and beneficiaries to bill for psychotherapy services that were medically unnecessary and never performed.

Including these charges, Medicare Fraud Strike Force operations in Detroit have charged a total of 138 individuals in cases involving approximately $148 million in fraudulent billings to Medicare.

These newly announced indictments bear out the advice that we have been delivering to clients, namely that the health care enforcement landscape is evolving and thus it is even more imperative to ensure that providers take pro-active steps to mitigate the likelihood that they will become subjects of the government's more robust initiatives to prevent health care fraud.

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April 20, 2010

April 2010 Monthly Review Reiterates HHA Accreditation and Change of Ownership Updates

In February, we blogged on the recent changes in home health agency (HHA) accreditation. In April 2010, NGS issued its Medicare Monthly Review, and reiterated the same HHA accreditation and change of ownership provisions. Particularly, the article discusses the requirements a deactivated HHA must meet in order to reactivate its billing privileges. It also discusses that an HHA may not undergo a change of ownership or transfer of ownership if the effective date of the change or transfer occurs within 36 months of: (1) the effective date of the provider's enrollment in Medicare, or (2) the effective date of the last ownership change or transfer for the HHA. The provider must instead enroll as a new HHA, undergo a state survey or obtain accreditation from a CMS-approved accrediting organization, and sign a new provider agreement.

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March 17, 2010

OIG Releases Compendium of Unimplemented Recommendations

Last week, the OIG released it's Compendium of Unimplemented Recommendations that "consolidates significant unimplemented monetary and nonmonetary recommendations addressed to the Department of Health & Human Services (HHS) to provide information to interested parties about outstanding recommendations...." While these have not been implemented, it is something we want our clients and readers to be aware of. It shows the direction the OIG is going and where it is focusing its efforts. Some relevant recommendations are below:

Hospices:
1. Due to the high number of hospices that were overdue in their certifications and due to the almost 50% of hospices having health deficiencies, the OIG recommends that CMS adopt statutory or regulatory changes to establish requirements for the frequency of certifications for hospice performance and for enforcing the remedies for a hospice's poor performance.
2. The OIG recommends that CMS strengthens its monitoring practices of hospice claims to ensure that they are properly submitted.

Home Health Agencies:
1. Due to the high levels of medically unnecessary care and fraudulent billing, the OIG recommends that CMS revise its regulations to require physicians to examine Medicare beneficiaries prior to ordering home health services.
2. For those HHAs performing poorly, the OIG recommends that CMS adopt and impose sanctions (besides termination from Medicare) to improve the quality of care.

Laboratory and Imaging Services:
1. To prevent over-utilization of laboratory testing, the OIG recommends that CMS reinstate beneficiary co-insurance and deductibles for lab tests.
2. The OIG recommends that CMS pursue legislation to set accurate and reasonable payment rates for lab tests as the carrier rates for nearly all lab tests varied.
3. Because few counties account for a large percentage of the Part B spending on ultrasound and because 20% of claims raised concern about whether or not they were appropriate, OIG recommends that CMS continue to monitor ultrasound claims to reduce Medicare's vulnerability to questionable ultrasound claims.

Again, these are merely recommendations and have not been implemented. However, they are useful in seeing where the OIG is looking to make changes and what kinds of changes we can expect from CMS in the future. We will continue to keep you apprised of any updates and regulatory changes as they develop.

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