Home Health & Hospice Week

Plus: Community physician pleads guilty in home care fraud case.

The results of an untested fraud calculation methodology may determine how much scrutiny you see from fraud-fighting authorities in coming years.

In its recently released Health Care Fraud And Abuse Control Program Report for 2014, the HHS Office of Inspector General notes that the Centers for Medicare & Medicaid Services will begin collecting data on probable fraud and have an estimate of probable fraud within home health agencies this year. “Documenting the baseline amount of fraud in Medicare is of critical importance, as it allows officials to better evaluate the success of ongoing fraud prevention activities,” the OIG says.

Guilty until proven innocent: “This project will estimate probable fraud in the Home Health benefit to pilot test the measurement approach and calculate a service-specific estimate,” the OIG explains. “A review panel of experienced health care analysts, clinicians, policy experts, and fraud investigators will review all collected data and determine if there is sufficient evidence to warrant a referral to law enforcement.”

See more about the pilot in the HCFAC report at http://oig.hhs.gov/publications/docs/hcfac/FY2014-hcfac.pdf.

Meanwhile, the authorities continue to rack up fraud convictions and guilty pleas in home care cases around the nation:

In Louisiana: Physician Winston Murray pled guilty to health care fraud charges, says the Department of Justice in a release. Murray admitted to writing home health referrals for patients in Hammond and New Orleans who were not homebound. Interlink Health Care Services Inc., Lake-land Health Care Services Inc. and others then submitted resulting claims for those patients for services that weren’t medically necessary and/or provided. Interlink and Lakeland billed about $2.2 million in the bogus claims based on Murray’s referrals. Murray is the ninth defendant to plead guilty in the case, and he’ll face sentencing in August. From 2007 through 2014, these HHAs and other companies involved in this scheme submitted more than $56 million in claims to Medicare, “a vast majority of which were fraudulent,” the DOJ says.

In Chicago: HHA owner Jacinto “John” Gabriel has received a 10-year prison sentence for Medicare fraud, following his guilty plea in February 2014 for health care fraud and tax evasion, the DOJ says in a release. Gabriel and 11 co-conspirators billed Medicare via HHAs Perpetual Home Health Inc. in Oak Forest, Ill., and Legacy Home Healthcare Services without beneficiaries’ knowledge or consent; paid kickbacks to physicians; and created false documentation to support the bogus claims, among other charges, according to prosecutors. Gabriel was indicted in 2011, and the co-conspirators in 2012.

In Miami: Felix Gonzalez was sentenced to more than nine years in prison after pleading guilty to health care fraud in January. Gonzalez, owner of AA Advanced Care Inc., admitted to billing Medicare for home care services that were not medically necessary or that weren’t provided at all, and to paying kickbacks for patient referrals and related paperwork, the DOJ says.

In Detroit: HHA owner Rahmat Begum pled guilty to Medicare fraud and money laundering during the second day of her trial, the DOJ says. Begum admitted to paying kickbacks to referring physicians and patient recruiters. She faces sentencing in August.

Also in Detroit: Father and daughter Abdul Malik Al-Jumail and Jamella Al-Jumail have been sentenced to 10 and four years in prison, respectively, for Medicare fraud. The Al-Jumails and another adult day care owner were convicted after a 12-week jury trial last fall, the DOJ notes in a release. The Al-Jumails obtained patients by paying kickbacks and caused claims to be submitted to Medicare for home health services, including physical therapy, that were never delivered.

In Rhode Island: The owner and former clinical director of Cranston HHA St. Jude Home Care has been charged with Medicaid fraud, according to a release from state Attorney General Peter F. Kilmartin. Prosecutors allege that between 2010 and 2013, St. Jude placed unlicensed certified nursing assistants (CNAs) in patients’ homes and fraudulently billed Medicaid for about $785,000 in CNA services. St. Jude was shuttered last summer under allegations of improper billing, when its Medicare and Medicaid billing privileges were terminated, notes The Providence Journal.

In Texas: The Texas Department of Aging and Disability Services has suspended the nursing license of Choice Home Care owner Terri Kahla, according to KBTX News 3. the suspension was based on the HHA’s lack of service to patients as well as not providing information for those patients to seek another agency.