Home Health & Hospice Week

Feds' first aim: Rogue agencies in Houston and L.A.

A sweeping new federal plan to ferret out fraudulent players in home health could have serious consequences for many agencies--and that means you.

The demonstration project, unveiled by the Centers for Medicare & Medicaid Services July 17, shocked even insiders with its timing and approach. Though the plan as announced focuses on "preventing deceptive providers from operating" in the greater Los Angeles and Houston areas, the crackdown demands the careful attention of law-abiding agencies in those locations, sources tell Eli.

"We are concerned with the broad brush approach CMS is taking," says Mary St. Pierre of the National Association for Home Care & Hospice, who added that the association was "quite surprised" by CMS' announcement.

Fear: The tactics employed could spread to other areas of the country.

"Home health has had a real honeymoon from fraud enforcement for at least the last five years and that is about to change," says Elizabeth Hogue, an attorney in Burtonsville, MD.
  
Re-Enroll Or Risk All

Under the plan, effective immediately, CMS will require home care providers that operate in the greater Houston and Los Angeles areas to resubmit enrollment applications to continue to participate as a qualified Medicare HHA.

One-two punch: The home health demonstration project announcement comes on the heels of another pilot project targeting fraudulent billing by suppliers of durable medical equipment, prosthetics, orthotics and supplies in South Florida and Los Angeles (see Eli's HCW, Vol. XVI, No. 24).

Big consequences: If providers in the targeted areas miss a request for action from CMS, they could be bounced out of the program--and fast.

"Those who fail to reapply within 60 days of receiving a notice to reapply from CMS will have their Medicare billing privileges revoked," states the agency in a press release announcing the program.

"Small mistakes could yield big problems," cautions attorney Deborah Randall, partner with Arent Fox in Washington, DC. "It is unclear at present whether a provider will be put out of the program with a right to appeal."

A New Kind Of Crackdown

The crackdown differs from those of the past in its emphasis on stopping fraud before it happens--or at least before it does irreparable harm to Medicare. In announcing the demonstration, CMS stressed its new ability to analyze Medicare billing in "real time," employing a team of federal, state and local investigators.

Pay off: That ability will help CMS prevent massive fraudulent billings, which the feds catch only after the fact through post-payment review--when payback is unlikely, notes Randall. "Nipping something in the bud is better for protecting the Medicare Trust Fund," she adds.

In addition to the new re-enrollment requirement, Houston and L.A. agencies could also lose their Medicare billing privileges for:

• Failing to report a change in ownership or change of address,

• Having owners, partners, directors or managing employees who have had a felony conviction within the last 10 years,

• Failing to meet "each and every" provider enrollment requirements.

Trouble ahead: "The demonstration requirements will be a real burden on law-abiding agencies," stresses St. Pierre. Even something as simple as relocation of an office, if left unreported, could be enough to land an agency in hot water, she adds.