Home healthcare agencies, aides top fraud list

Medicaid fraudHome healthcare agencies and home healthcare aides topped the list of providers with the largest number of healthcare fraud convictions in 2014, according to a report released last month by the HHS Office of the Inspector General.

Of the more than $1.9 billion recovered in total civil judgments and settlements, the federal government recovered $186 million from civil fraud Medicaid cases involving home health agencies.

Criminal convictions of home healthcare aides represented 30 percent of all Medicaid Fraud Control Unit (MFCU) criminal convictions; up from 26 percent in 2013. Most commonly, home health care aides were convicted of fraud, often for claiming to have rendered services that were not provided, according to the report.

The government recovered $12 million from convictions of home health care aides and another $546,790 from 21 civil settlements and judgments.

Overall, the Medicaid Fraud Control Unit reported 1,318 criminal convictions in 2014, similar to 2013’s total of 1,344 criminal convictions.

About three-quarters of criminal convictions (73 percent) involved fraud; about one-quarter (27 percent) involved patient abuse and neglect. The convictions for fraud included conspiracy to commit health care fraud, submitting false statements related to health care matters, making false statements in regard to healthcare reimbursements, grand larceny, violations of anti-kickback statutes, and improperly prescribing drugs.

Cases of patient abuse and neglect included aggravated assaults, injury to elderly or disabled persons, and theft of patient funds. The report cites as an example the investigation of the owner of an adult family care home in Florida for allegations including neglecting residents, failing to provide medical services for a resident’s wounds, willfully abusing a disabled adult, and financially exploiting residents. The owner was convicted and sentenced to more than 8 years in prison.

Of the 874 civil settlements and judgments obtained by the MFCU, most involved pharmaceutical manufacturers, pharmacies, and suppliers of durable medical equipment. Cases involving pharmaceutical manufacturers accounted for about half (52 percent). Pharmacies were the second most common provider type for civil settlements and judgments while durable medical equipment were the third most common

Individuals and entities convicted of a program related crime are excluded from federally funded healthcare programs – usually Medicare and Medicaid. That means that no payment is made for items or services provided or prescribed by that entity.

Being excluded from Medicare and Medicaid can have a devastating impact on an individual provider’s career and finances. It can severely limit employment opportunities. For example, an excluded individual is prohibited from serving in an executive or leadership role (i.e. CEO, CFO, general counsel, director of health information management, director of human resources, physician practice office manager, etc.) at a provider that furnishes items or services payable by federal health care programs. In addition, an excluded individual may not provide health information technology services and support, strategic planning, billing and accounting, staff training, and human resources, unless entirely unrelated to federal health care programs.

You can read more about what such exclusion can mean to your practice by clicking here.

The Centers for Medicare and Medicaid has been expanding its crackdown on fraud and abuse by home health agencies. On Jan. 30, CMS announced a temporary moratorium on the enrollment of home health agencies in four cities including Fort Lauderdale. It also is extending, for another six months, the existing enrollment moratoria of home health agencies in several cities, including Miami.

The Health Law Offices of Anthony C. Vitale represents home health agencies as well as other providers in a number of different matters including fraud and abuse defense. If you have any questions relating to this, or other healthcare related matters contact us at 305-358-4500.

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It is not intended as professional advice and should not be construed as such.