Home Health & Hospice Week

Home care providers targeted in latest national takedown.

Don’t feel like you are safe from enforcement actions just because you aren’t in a HEAT Medicare Fraud Strike Force city.

The Department of Justice carried out “the largest criminal health care fraud takedown in [its] history” on June 18, Attorney General Loretta Lynch says in a release. Authorities charged 243 individuals in 17 districts for about $712 million in false billing, including home health agency claims.

Many of the busts occurred outside of the nine HEAT Medicare Fraud Strike Force cities of Baton Rouge, La., Brooklyn, N.Y., Chicago, Dallas, Detroit, Houston, Los Angeles, Miami–Dade, and Tampa Bay, Fla.

For example: In Ohio, five individuals were charged in a $7 million false billing case involving HHAs Just Like Familee II Inc. and Just Like Familee III Inc., the DOJ says in a separate release. The companies had locations in Cleveland Heights, Twinsburg, and Mentor.

The defendants billed for services never rendered, then falsified records to support the bogus visits, prosecutors allege. In addition to seeking the money from the scheme, prosecutors are seeking forfeiture of a home in Macedonia owned by Delores L. Knight, and a home in Twinsburg owned by Theresa L. Adams.

Home Care Makes Up Two-Thirds Of Target Areas

This takedown was almost twice the size of the previous ones DOJ had conducted, notes the HHS Office of Inspector General in a fact sheet. This operation focused on three target areas: (1) Medicare home health benefits, (2) Medicaid Personal Care Services (PCS), and (3) Medicare Part D prescription drugs.

“Medicare home health services fraud is a priority of the Office of Investigations and represents a significant fraud scheme noted in today’s operation,” the OIG said. “Home health fraud frequently involves criminal enterprises and cooperative beneficiaries.”

The spike in PCS billing has landed it on the feds’ radar. In 2011, Medicaid costs for PCS totaled about $12.7 billion — a 35 percent increase since 2005, the OIG notes.

Pros And Cons Of Enforcement Style

The DOJ is “still following an approach long used by narcotics investigators,” believes attorney Mark Silberman with law firm Duane Morris. In other words, the feds are “identifying someone with ‘low level’ culpability, developing informants, working up the chain-of-command to the ‘leaders’ of the operation, take a picture with a big pile of drugs, declare victory, celebrate, repeat,” Silberman says in analysis posted on the Duane Morris website.

The benefits of an all-at-once crackdown is that the large scope draws attention to “a serious problem,” says Silberman, a former narcotics prosecutor. And it drives other bad actors out of the area. “The dealers knew what they had done, but did not know who we had arrest warrants for and did not want to wait around to find out,” he recalls. “Presumably, this sweep may deter those who are committing (or considering) healthcare fraud.”

But these tactics may not work well for health care fraud, contends Silberman. “Trading up the criminal ‘chain-of-command’ only works if the degree of culpability follows a consistent progressive hierarchy,” he notes. “In healthcare fraud that’s not always true. Who is prompting or encouraging the fraud varies. It could be the owner, the patient, the nurses, the doctors, the recruiters, the billers … anyone involved in the transaction can lead it astray.”

Big takedowns do scare people away, “but not always the right people,” Silberman argues. “Healthcare professionals are under attack and many quality professionals feel like even an honest mistake will subject them to scrutiny for potential fraud. They are not wrong.”

The result: “Many quality and honest healthcare professionals are deciding that being presumptively viewed as suspects is just not worth it,” he believes. “Some are leaving healthcare — others, more commonly, are abandoning the Medicare and Medicaid system — thus denying the recipients of government-sponsored healthcare access to quality healthcare providers.”

Bottom line: “The government needs to be aware of the unintended consequences of its actions — no matter how laudable its motives may be,” Silberman stresses.