Home Health & Hospice Week

The industry is still living down the Dr. Jacques Roy case.

Don't expect fraud and abuse scrutiny to let up any time soon, with the HHS Office of Inspector General reporting $2.4 billion in judgements and settlements in fiscal year 2017 thanks to its fraudfighting efforts.

The Health Care Fraud and Abuse Control Program operated jointly by the OIG and the Department of Justice resulted in 967 new criminal health care fraud investigations by the DOJ last year, according to the annual report on the program.

Federal prosecutors filed criminal charges in 439 cases involving 720 defendants, with a total of 639 defendants convicted of health care fraud-related crimes during the year. The DOJ also opened 948 new civil health care fraud investigations and had 1,086 civil health care fraud matters pending at the end of the year, the report says.

On the OIG side, investigations resulted in 788 criminal actions against individuals or entities and 818 civil actions, which include false claims and administrative recoveries related to provider selfdisclosure matters. The OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.

Not surprisingly, the OIG focuses on a number of home health and hospice fraud topics and cases in the report. Those included high-profile cases it also reported in its latest semiannual report to Congress, such as convictions secured for Dr. Jacques Roy (see Eli's HCW, Vol. XXVI, No. 22) and Just Like Familee execs (Vol. XXVI, No. 8). Also cited were cases against mother-and-daughter HHA owners in Miami Mildrey Gonzalez and Milka Alfaro (Vol. XXVI, No. 10) - although not by name - and ones in Houston and Detroit.

As well, the report includes the convictions for the owner and medical director of Christian Home Health in New Orleans, although a federal judge overturned those convictions earlier this year (Vol. XXVII, No. 6).

And the OIG notes its exclusion authority, pointing out it excluded District of Columbia-based agency Global Healthcare Inc. owner Florence Bikundi for 55 years. Bikundi and others in the case also faced convictions, lengthy prison sentences, restitution and more (Vol. XXV, No. 22).

The OIG notes its success in limiting HHAs' abuse of outlier payments via the home health outlier cap implemented in 2010, noting that cap payments fell from a peak of $19.5 million that year to $18.5 million the following year, and have stayed around the $18 million mark since then.

One fraud-fighting program, called the Large Scale Conspiracies Initiative, has been successful in bringing down wide-scale health care fraud schemes. That includes "an 18-month FBI undercover operation [that] collected evidence to ensure prosecution of significant health care fraud encompassing over $90 million in Medicare losses, incurred by over 200 home health care facilities and four clinics submitting false claims." That resulted in the 40-year prison sentence for one Houston physician, the report says.

"The FBI is committed to addressing this type of crime problem through the disruption, dismantlement and prosecution of those involved in criminal enterprises and other organized criminal activities," according to the report.

The report also references an earlier finding that Medicare Administrative Contractors collected only 11 percent of the home health and hospice overpayments referred by Zone Program Integrity Program Contractors and Program Safety Contractors in 2014. That compares to an average 20 percent rate across all Medicare provider types.

The OIG reiterated its recommendation to implement surety bond requirements for home health agencies, as well as other high-risk providers.

Note: See the 95-page report at https://oig.hhs.gov/publications/docs/hcfac/FY2017-hcfac.pdf.