Home Health & Hospice Week

Will egregious fraud cases hurt the entire industry?

With serious legislative consequences for home health agencies hanging in the balance this year, the OIG’s take on the industry is more important than ever. The watchdog agency offers its fraud and abuse perspective in its latest Semiannual Report to Congress — and it’s not a warm fuzzy hug.

Reminder: For HHAs, Congress may blunt the worst of the payment cuts related to behavioral adjustments (see HHHW, Vol. XXXI, No. 43). And sequestration cuts are also a topic that is in play.

“Failure to waive Statutory PAYGO sequester cuts would result in $38 billion in Medicare cuts in fiscal year 2023 which would have a devastating impact on the health care field, destabilizing health care access,” insists the National Association for Home Care & Hospice in its member newsletter. The sequestration cuts would total 4 percent.

“In previous years Congress has stepped in to pass legislation to avoid triggering PAYGO,” NAHC notes. “Congress once again needs to waive these cuts, to prevent them from taking effect in 2023. We urge Congress to prevent these cuts. Now is not the time for reductions in Medicare payments to providers,” the trade group maintains.

Lawmakers will base decisions on those items, and much more, in part on information from sources including the HHS Office of Inspector General Semiannual Report to Congress.

And what does the report issued on Dec. 5 have to say? Not as much as in some years, but it may still be enough to influence legislators.

For home health, the OIG lists two high-profile fraud cases.

Case No. 1: SHC Home Health Services of Florida and its related entities known as Signature HomeNow paid $2.1 million to the U.S. government to settle claims of improper billing, the OIG notes in the report. Signature HomeNow, whose corporate headquarters is in Louisville, Kentucky, submitted false home health claims for Medicare beneficiaries who were not homebound; did not require certain skilled care; did not have a valid plan of care in place; and/or did not have appropriate face-to-face encounters.

The case arose from both a whistleblower lawsuit and a complaint to the OIG fraud hotline, the Department of Justice noted back in May (see HHHW, Vol. XXXI, No. 17).

Case No. 2: In September, Oklahoma-based Carter Healthcare agreed to pay $7.175 million to resolve allegations that it submitted claims for medically unnecessary home health therapy services to Medicare beneficiaries in Florida, the report highlights. And Carter agreed to pay a whopping $22.9 million to resolve charges that it submitted claims in violation of the anti-kickback statute by paying physicians remuneration under the guise of medical directorships in order to induce referrals of home health patients in Oklahoma. Carter entered into a five-year CIA with the OIG and the agency excluded CEO Stanley Carter and Chief Operating Officer Brad Carter from participation in federal health care programs for five years.

This case arose from two different qui tam lawsuits, the DOJ said (see HHHW, Vol. XXXI, No. 17). The relators in the therapy-based case received $1.3 million of the settlement.

In general, the report projects nearly $4 billion in expected recoveries resulting from HHS OIG audits and investigations occurring between Oct. 1, 2021 and Sept. 30, 2022, it says in a release about the report. The OIG reported 710 criminal enforcement actions and 736 civil actions, and excluded 2,332 individuals and entities from participation in federal health care programs.

Note: The 122-page report is at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2022/fall-sar-2022.pdf.