Home Health & Hospice Week

Suppliers get good report for hurricane service, however.

Suppliers shouldn't expect fraud and abuse scrutiny to let up after the HHS Office of Inspector General's latest report to Congress.

In its December semiannual report to Congress, the OIG includes a laundry list of durable medical equipment suppliers brought up on fraud charges in Florida, Texas, and California.

Case #1: In Florida, an Administrative Law Judge upheld the OIG's penalty against a Clear-water, Fla.-based DME supplier. The ALJ affirmed the OIG's imposition of a $100,000 civil money pen-alty, a $42,220 assessment, and a seven-year exclusion against Cary Frounfelter and Kast Orthotics and Prosthetics Inc., the OIG says in the report.

Frounfelter and Kast falsely claimed they provided custom-made orthotic devices after beneficiaries had been discharged from HealthSouth Rehabilitation Hospital in Largo, Fla., or within a 48-hour window prior to discharge, the OIG alleges. They then illegally billed the devices to Medicare Part B. Frounfelter and Kast struck a "corrupt bargain" with HealthSouth, the OIG claims in the report.

Case #2: In Texas, wheelchair suppliers Pi-us Ekiko and Harold Iyalla paid two doctors for false wheelchair certifications and billed Medicare for pricier wheelchairs when really furnishing less expensive scooters. The DME owners, a patient recruiter, and the two physicians were sentenced to more than 380 months in prison and ordered to pay more than $18 million in restitution, the OIG says.

Case #3: The Medicare Fraud Strike Force in South Florida and in California is using "real-time analysis of Medicare billing data, as well as findings from investigations, in its ongoing efforts to identify, investigate, and prosecute individuals and companies that have committed DME fraud," the OIG says.

The South Florida Initiative has resulted in 50 convictions and $68.9 million in "investigative receivables," the OIG says.

The OIG also noted its recent reports on the DME sector, including its high-profile slam of DME CERT numbers (see Eli's HCW, Vol. XVII, No. 31, p. 242) and a report that found disaster-related DME claims for 2005 hurricane victims all checked out.

The report is online at www.oig.hhs.gov/publications/docs/semiannual/2008/semiannual_fall2008.pdf.

• Home health agencies and hospices got a pass in the OIG's latest report to Congress.

The semiannual report contained a recounting of recent OIG reports on duplicate HHA supplies, survey deficiencies (see Eli's HCW, Vol. XVII, No. 29, p. 226), and hospice respite care (see Eli's HCW, Vol. XVII, No. 14, p. 110). But the OIG didn't single out any HHA or hospice enforcement cases to highlight.

• Home care providers that pay staff based on the IRS's mileage rate may save some money in the new year. The Internal Revenue Service has lowered its rate to 55 cents per mile, down from the current 58.5 cents. The change takes effect Jan. 1.

In 2006, rates were 44.5 cents per mile, points out the National Association for Home Care & Hospice.

• Home health agencies can expect more abrupt payment suspensions if they are suspected of Medicare fraud. Last month, a Miami federal court dismissed a lawsuit against the payment suspensions CMS imposed in response to outlier fraud in the area (see Eli's HCW, Vol. XVII, No. 36, p. 282).

U.S. District Judge Paul Huck sided with Medicare in Home Care Services Provider vs. Leavitt, saying the program's suspension policy is "reasonable and appropriate," according to the Miami Herald.

"'Because of the judge's decision, we will be able to expand our efforts to look at other home healthcare companies for payment suspensions and audits," Medicare spokesperson Peter Ashkenaz told the newspaper.

"The ruling of the court paves the way for Medicare to continue to use a strong hand to ferret out any abusive practices relative to outlier claims," NAHC says. Medicare has told the trade group that more than 250 of the 350 agencies serving Miami-Dade have more than 60 percent of their claims as outliers, it says. This compares to about 3 percent of claims for all providers outside of Miami-Dade.

• CMS has added more people to the list of professionals who are exempt from the durable medical equipment accreditation requirements that take place Sept. 30, 2009. Orthotists, prosthetists, opticians, and audiologists are now on the exempt list, CMS says in a message to providers.

Professionals such as pedorthotists, mastectomy fitters, orthopaedic fitters/technicians and athletic trainers are not exempt, clarified CMS's Sandra Bastinelli in the Dec. 9 Open Door Forum for home care providers.

• HHAs' workers' comp duties extend only as long as the work day, and that doesn't include coming to and going from work, a recent court decision shows.

Home health aide Emma Mitchell claimed workers' comp costs from Cambridge Home Health Care Inc. in Ohio when she tripped and fell on a floor mat, injuring her leg, when leaving her patient's apartment building. The state's Industrial Commission and a county court disallowed her claims due to the "coming and going" rule, says a Sept. 10 decision from the state's Ninth District Court of Appeals.

In her appeal, Mitchell argued that the hallway and elevator were still part of her workplace and that the coming and going rule didn't apply to a building.

"We reject Mitchell's narrow reading of the coming and going rule," the court says in the Mitchell v. Cambridge Home Health Care decision (CV 05 09 5393). "So long as an injury takes place outside the situs [job site], the location of that injury is irrelevant." Mitchell also didn't qualify for any rule exceptions, the Court added. The decision is at http://ohiosupremecourt.gov/rod/docs/pdf/9/2008/2008-ohio-4558.pdf.

• Suppliers can only bill coupling gel to local carriers, not to DME MACs, CMS says in a correction to an earlier transmittal. The gel is assigned HCPCS code A4559, CMS says in Dec. 5 CR 6062 (Transmittal No. 1644).

• Palmetto GBA and the Fiscal Interme-diary Shared System (FISS) are working on a solution for a claims system error. The system is assigning the same Document Control Number (DCN) to multiple claims, regional home health intermediary Palmetto reports on its Web site. That puts the claims into holding at location SM95HG.

"The FISS maintainer and the Data Center are actively working on a resolution," Palmetto says. "DDE claims submitted on or after 12/3/08 that are 'clean' should go to status and location SB9000. Claims that have been in status and location SM95HG will remain in this location until the fix."

• Home care providers should keep a wary eye on the big health care reform package that's taking shape. President-elect Barack Obama and congressional leaders are already indicating their preferences for the bill, and fixing the perpetual physician payment shortfall is one of the items on their wish list.

To fix the physician payment problem, Congress will need to raise money from another sector under pay-go rules. Prime candidates for the chopping block are home health agencies with their double-digit profit margins and MedPAC cut recommendations, hospices with their explosive industry growth, and suppliers with their fraud and abuse reputation problems, observers say.

• Don't make the mistake of billing patients for their telemonitoring services. Even though Medicare doesn't explicitly pay home health agencies for telemedicine, agencies can't charge beneficiaries for the service, RHHI Palmetto GBA says in its recently released 16-state coalition questions and answers from September.

CMS's Medicare Benefit Policy Manual, Chapter 7, Section 110 states, "Telehealth services are outside the scope of the Medicare home health benefit and home health PPS," Palmetto says in the Q&A. "As such, a home health agency may not bill Medicare for reimbursement of the telemonitor."

Section 110 further states, "There is nothing to preclude an HHA from adopting telemedicine or other technologies that they believe promote efficiencies, but ... those technologies will not be specifically recognized or reimbursed by Medicare under the home health benefit." Telemonitoring still requires a physician certification of a home health plan of care, Palmetto adds.

• A recent study published in Nature Neur-oscience suggests that controlling the level of a fatty acid in the brain could help treat Alzheimer's disease. Tests conducted on mice showed that reducing excess levels of fatty acid lessened animals' memory problems and behavioral changes. Researchers at the Gladstone Institute of Neurological Disease and the University of California said fatty acid levels could be controlled through diet or drugs.