Home Health & Hospice Week

Plus: Watchdog agency takes ZPICs to task for overlooking HHA fraud.

As 2014 budget negotiations pick up speed, law- and policymakers are getting an earful from the HHS Office of Inspector General about home health agency fraud.

In its latest Semiannual Report to Congress, the OIG highlights four high-profile cases of Medicare home health agency fraud.

Case #1: The feds have indicted seventeen defendants in a case involving Miami-based Super-star Home Health Care Inc. Superstar "allegedly offered and paid thousands of dollars in kickbacks and bribes to patient recruiters and Medicare beneficiaries," the OIG says. "Superstar used beneficiary information to submit $1.5 million in claims to Medicare for home health services that either were medically unnecessary or were not provided." The 17 defendants were sentenced to a total of 17 years incarceration, the OIG says in the report.

Case #2: Two RNs employed by Ideal Home Health Inc. in Miami allegedly "falsified and caused Medicare beneficiaries to falsify Weekly Visits and/or Time Records sheets, which indicated that they provided skilled nursing services to Medicare beneficiaries," the OIG says in the report. Kelvin Soto was sentenced to six years of imprisonment and ordered to pay $727,418 in restitution. Odalys Fernandez was sentenced to three years and five months of imprisonment and ordered to pay $240,369.

Case #3: Kai Heart Home Health Care in Texas allegedly falsified OASIS certifications, the OIG says. "Kai Heart knowingly altered the OASIS forms by upcoding the severity of patients’ conditions in order to receive additional Medicare reimbursement." Kai Heart agreed to pay $778,093 to re-solve the False Claims Act allegations and to enter into a Corporate Integrity Agreement.

Case #4: Willsand Home Health Services Inc. owner Eulises Escalona paid kickbacks to patient recruiters, signed false documents stating that recruited patients received home care services, and paid kickbacks to physicians in return for signing false prescriptions, resulting in $40 million in bogus claims, according to court documents. Escalona was sentenced to 10 years in prison and ordered to pay $26 million in restitution after pleading guilty, the OIG says in the report.

The OIG also reemphasized its December 2012 report in which it took Zone Program Integrity Contractors to task for ignoring suspicious home health activity in their areas. "The two CMS Medicare Administrative Contractors (MACs) we reviewed prevented $275 million in HHA improper payments and referred several instances of potential fraud, but the four ZPICs we reviewed did not identify any HHA-specific vulnerabilities and varied substantially in their efforts to detect and deter fraud," the OIG criticizes.

And the OIG was unhappy that Medicare inappropriately paid five HHAs with suspended or revoked billing privileges in 2011.