Home Health & Hospice Week

Pro tip: Calling a payment to a physician a ‘copay’ doesn’t mean it’s not a kickback.

Hunting health care fraud is big business for the feds, and the latest annual Health Care Fraud and Abuse Control Program Report shows why it will continue.

“During Fiscal Year (FY) 2021, the Federal Government won or negotiated more than $5 billion in health care fraud judgments and settlements, in addition to other health care administrative impositions,” the Departments of Health and Human Services and Justice say in their report summary. “Because of these efforts, as well as those of preceding years, almost $1.9 billion was returned to the Federal Government or paid to private persons in FY 2021,” HHS and the DOJ crow.

Specifically, the DOJ opened 831 new criminal health care fraud investigations in 2021, with federal prosecutors filing criminal charges in 462 cases involving 741 defendants. A total of 312 defendants were convicted of health care fraud-related crimes during the year. The DOJ also opened 805 new civil health care fraud investigations and had 1,432 civil health care fraud matters pending at the end of the fiscal year.

The DOJ isn’t the only enforcement show in town. Federal Bureau of Investigation “investigative efforts resulted in over 559 operational disruptions of criminal fraud organi­zations and the dismantlement of the criminal hierarchy of more than 107 health care fraud criminal enterprises,” the report celebrates. And investigations conducted by the HHS Office of Inspector General resulted in 504 criminal actions and 669 civil actions. The OIG also excluded 1,689 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.

The report shines a spotlight on a relatively high number of home health cases this time around. For one case, the OIG and DOJ give a shout-out to the Senior Medicare Patrol program, which provided $17.6 million to 54 grantees to “educate and empower Medicare beneficiaries to prevent, detect, and report Medicare fraud, errors, and abuse” in 2020 (see SMP data update for 2021, p. 194).

Over half of the SMP’s $16.8 million in recoveries in that year “came from one project that uncovered a fraud scheme in which a provider paid beneficiaries to receive home health services that were never rendered,” the report recounts. “The provider then submitted fraudulent claims to Medicare for millions of dollars while also receiving illegal kickback payments from the home health agencies. The provider was sentenced and ordered to pay a total of $9.5 million in restitution and forfeitures,” the OIG and DOJ say.

Another SMP project reported nearly $5 million in expected Medicare recoveries after uncovering multiple statewide fraud schemes that involved enrolling beneficiaries in medically unnecessary hospice services, the report says. “These services were often provided against the beneficiaries’ wishes, and at times, interfered with their proper medical care and medications,” the OIG and DOJ report.

The OIG “focuses on combating Medicare and Medicaid fraud, waste, and abuse, including in priority areas such as … enhancing program integrity in noninstitutional care settings, such as home health and hospice care,” the report says.

The report also covers the problems it has with Medicare Advantage Organizations that don’t require physician NPIs for docs who order home health and other services. “We recommended that CMS encourage MAOs to perform program integrity oversight using ordering NPIs,” OIG reiterates from a report it issued last year.

Other home health and related cases highlighted in the report include:

In Florida: Four defendants were sentenced for their roles in an $80.4 million home health fraud scheme during the report period. “Three sham home health agencies … never treated a single patient, yet billed Medicare for over $80.0 million in fraudulent claims, of which they received approximately $50.0 million,” the report says. The group’s “money mule” received a sentence of about 8 years; the “first kingpin and his lieutenant” received sentences of 17.5 years and 10 years, respectively; and “the second kingpin” was also sentenced to 17.5 years, the OIG and DOJ recount. The individuals laundered the proceeds through dozens of shell companies and evaded law enforcement detection for years by requiring nominee owners of the HHAs and shell companies to permanently flee to Cuba upon the conclusion of their involvement in the scheme. (See more details of the case in HCW by AAPC, Vol. 30, No. 20.)