Home Health & Hospice Week

MFCUs recover more than $6 for every $1 spent on enforcement activities.

Sometimes Medicare fraud cases get all the headlines, but the feds are focusing on Medicaid enforcement too.

In its recently released strategic plan for 2020-2025, the HHS Office of Inspector General singles out Medicaid Personal Care Services as a “key oversight area.” The OIG “has identified systemic problems related to the design and delivery of Medicaid PCS, as well as instances of patient harm,” the watchdog agency continues. “Over the past 6 years, OIG has opened more than 200 investigations involving fraud and patient harm and neglect in the PCS.”

The OIG’s emphasis on Medicaid home health doesn’t mean it has forgotten its Medicare home health focus, however. The agency “has identified program integrity for home and community-based services as a top management challenge for HHS. We have issued more than 30 audits and evaluations, recommending the recovery of over $700 million and improvements to service delivery,” the strategic plan notes.

And don’t expect the OIG to let up during the pan-demic. The agency “seeks to foster quality and safety of services provided in home and community settings during disease outbreaks and other emergencies,” it stresses.

Resource: The 25-page strategic plan is at https://oig.hhs.gov/about-oig/strategic-plan/OIG-Strategic-Plan-2020-2025.pdf.

OIG Hits Medicaid Hard In Recent Round Of Reports

In recent months, the OIG has issued reports pointing out varied problems with states’ Medicaid administration for home health and hospice and the program in general:

• MFCUs: In 2019, Medicaid Fraud Control Units recorded 47 convictions related to home health agencies and 14 civil settlements and judgments, related to more than $79 million in resulting recoveries. MCFUs also reported 55 convictions of personal care and home care aides and nearly $56,000 in aide-related recoveries. At the end of 2019, MFCUs had 75 criminal and 95 civil HHA fraud cases open.

Hospices didn’t escape MFCUs’ efforts. The units reported four hospice-related convictions and two settlements or judgements related to more than $933,000 in recoveries for the year. MFCUs also had 74 criminal and 33 civil hospice investigations open at the end of 2019, plus three hospice patient abuse or neglect cases, the OIG says.

Overall, MFCUs secured 1,527 convictions, 658 civil settlements or judgments, and 1,235 individuals and entities from federal health programs in 2019. MCFUs recovered a whopping $1.9 billion in the year — recovering $6.41 for every dollar spent.

Resource: The 33-page MFCU report is at https://oig.hhs.gov/oei/reports/oei-09-20-00110.pdf.

• Terminated providers: Medicaid programs are messing up by paying terminated providers, the OIG accuses in a recent report. “Nearly 1,000 terminated providers — or 11 percent of all terminated providers — were inappropriately enrolled in State Medicaid programs or were associated with $50.3 million in Medicaid payments after being terminated,” the OIG notes in a report summary. “These providers had been terminated for reasons such as criminal convictions, licensure issues, and provider misconduct and thus potentially posed a risk to beneficiaries’ safety and quality of care.”

Resource: The 43-page report is at https://oig.hhs.gov/oei/reports/oei-03-19-00070.pdf.

• Unenrolled providers: In a review of all 50 states, the OIG found that 23 states “had not enrolled all providers serving Medicaid beneficiaries in their respective Medicaid programs. As a result, beneficiaries were exposed to potentially harmful providers that had not been screened for fraud, waste, and abuse,” the agency says in a report summary.

Of the 27 states that had enrolled all providers, 16 “reported that they were not in compliance with the requirements to collect identifying and ownership information necessary for effectively screening Medicaid providers, or that they lacked enforcement controls to ensure ongoing State compliance with provider enrollment requirements,” the OIG found.

Resource: The 51-page report is at https://oig.hhs.gov/oei/reports/oei-05-19-00060.pdf.

Mental Health Services Trigger Settlement

The Department of Justice has been announcing multiple Medicaid fraud cases of home health providers, including this recent one in Maine.

Portland-based Noble Home Health Care Inc. and its owner Mohamed A. Hassan have agreed to pay $111,200 to settle allegations that they violated the False Claims Act, the DOJ says in a release. Noble and Hassan submitted false claims for reimbursement to MaineCare for services provided to children with mental health diagnoses, despite the fact that Noble did not hold the necessary mental health licensure to bill for such services.

After Maine Department of Health and Human Services officials informed Hassan several times that Noble could neither provide nor bill for mental health services, Noble and Hassan billed for 45 patients over five months anyway, the DOJ says.