Home Health & Hospice Week

State plans to tighten background checks.

Members of the home health industry know there are fraud hot spots around the country, most notably evidenced by the existing moratoria areas and the HHS Office of Inspector General Medicare Fraud Strike Force cities.

But now that information has caught mainstream attention, thanks to investigative journalism by The Chicago Tribune. In a lengthy article, the Trib discusses the preponderance of fraud in both the home health and physician home practice industries in Chicago, and the interaction between the two ranging from kickbacks for referrals to false certifications.

For example: The newspaper pores over the details of the case against nurse and physician staffing company manager Diana Jocelyn Gumila of Suburban Home Physicians dba Doctor at Home. From 2013 through May 2014, more than 300 home health agencies submitted Medicare claims ordered by just four Doctor At Home physicians to provide home health services to 4,000 patients, the Department of Justice said back in 2014. Those HHAs were paid more than $20 million as a result of their claims (see Eli's HCW, Vol. XXV, No. 16).

Gumila outsourced record falsification to accomplices in the Philippines, the newspaper reports. And Chicago has "a shadow market of patient brokers who troll grocery stores, bus stops, churches and food pantries in search of susceptible adults," the Trib claims. Illegal kickbacks for new patients are "commonplace."

Price: HHAs have improperly collected $104 million over the past five years, the article claims. The moratoria hasn't helped stem the fraud tide much, because existing licenses are offered for sale via the internet, the newspaper says. Illinois' licensing department also lets fraudsters easily open new locations, the Tribune claims. And a lack of resources means federal investigators take on only the most blatant of fraud cases.

In Gumila's case, she was convicted of fraud and sentenced to six years in prison and more than $15 million in restitution last year.

Each year, state officials survey about 163 businesses and conduct 53 complaint investigations, the Tribune found. "Officials substantiated minor violations, on average, in less than 1 in 5 cases, which were resolved with written plans of correction. A department spokeswoman acknowledged that 'no major enforcement actions have been taken against home health agencies' in the last five years."

Cook County now "harbors more home health companies than the entire and more populous state of New York," the newspaper adds. "At least 357 active home health companies in the Chicago area have been linked to potential financial fraud by federal investigators but never charged."

The piece also laments the halt of the Pre-Claim Review program, although it does acknowledge the program's heavy burden on legitimate agencies.

Result: In response to the article, Illinois officials say "they plan to modify state regulations to require a more thorough background check on previous employment" for HHA owners and employees.

Note: See the in-depth article at www.chicagotribune.com/news/watchdog/ct-home-health-mainmet-20171212-story.html.