Home Health Agency Settles Allegations Relating to Excluded Provider

A blue door with two small holes in it.

A Connecticut home healthcare company and its owner have agreed to pay a little more than $28,000 to settle allegations that they improperly employed a physical therapist who had been excluded from all federal healthcare programs.

The U.S. Department of Health and Human Services Office of Inspector General (OIG) has the authority to exclude individuals and entities from federally funded healthcare programs such as Medicare and Medicaid for various reasons.

There are two types of exclusions mandatory and permissive.

  • Mandatory is for those convicted of Medicare or Medicaid fraud, patient abuse/neglect, felony convictions for other healthcare related fraud, theft or other financial misconduct as well as felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
  • Permissive exclusions give OIG discretion to exclude individuals and entities on various grounds including misdemeanor convictions relating to healthcare fraud, misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements; defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee.

According to the U.S. Attorney’s Office for the District of Connecticut, Careco Medical, Inc. and its owner and CEO Helga Pfanner, hired Todd Roberts for a management position in November 2018, where he served in that job until March 2019.

Roberts pleaded guilty in 2012 to one count of obstructing a federal audit and agreed to pay $328,828 as part of a settlement agreement.  In addition, he entered into a six-year Integrity Agreement with the U.S. Department of Health and Human Services designed to ensure future compliance with the requirements of the Medicare program. However, Roberts later defaulted on his obligations and was excluded from all federal healthcare programs in 2015.

By law, providers who submit claims to a federal healthcare program for any services or items furnished or ordered by excluded providers face both monetary penalties and possible exclusion from federal healthcare programs themselves.

As we wrote about late last year, OIG excluded 2,148 individuals and entities from participation in federal healthcare programs in 2020.

The federal government offers a list of providers who have been excluded. The database is known as the List of Excluded Providers or LEIE. Because the government does not send out notifications of who has been excluded, it is incumbent on those who hire providers to check that database to confirm that potential hires, as well as existing employees, are not on it. The list is updated monthly.

Those who have been excluded must seek reinstatement, it is not automatic once the period of exclusion ends. OIG has the authority to waive an exclusion under certain conditions which can be found here.

If you learn that you have an excluded provider working at your healthcare organization, or that your organization has billed for services ordered by someone excluded from the program, it’s best that you consult a healthcare attorney to determine the next steps to take.

The Health Law Offices of Anthony C. Vitale prepares narrowly tailored, provider specific compliance programs which can assist in avoiding such an oversight from occurring. For information call 305-358-4500 or email info@vitalehealthlaw.com

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