A nationwide healthcare company based in Dallas, Texas, along with its subsidiaries, has agreed to pay $3,850,000 to resolve allegations of violating the False Claims Act. The allegations pertain to two aspects of its business operations. First, the company is accused of knowingly submitting claims to Medicare for home healthcare services for patients who did not qualify for the Medicare home healthcare benefit or where the services did not meet Medicare reimbursement criteria. Second, the company is also accused of knowingly submitting claims to Medicare for patients who did not qualify for the hospice benefit.
The United States alleged that, between 2016 and 2021, 19 of the company’s home healthcare facilities submitted claims for services provided to patients who either did not qualify or were not properly certified for the Medicare home healthcare benefit. These services were allegedly not reasonable or medically necessary, were provided by untrained staff, or were not performed at all. Additionally, the United States alleged that, during the same period, three of the company’s hospice facilities admitted patients to hospice care who were not terminally ill or continued to provide services to patients who should have been discharged because they no longer met the Medicare hospice benefit requirements.
“Home health is designed to increase healthcare access for our most vulnerable populations with mobility limitations, while hospice care aims to provide comfort and relief for the terminally ill. Exploiting these systems for financial gain is intolerable,” said Special Agent in Charge Tamala E. Miles of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “Working with our law enforcement partners, we will continue to pursue healthcare providers who jeopardize the integrity of these services by prioritizing profit over medically necessary palliative care.”
Compliance Perspective
Issue
Submitting claims for payment to Medicare or Medicaid that are known or should be known to be false or fraudulent is illegal. This includes the falsification of documents, incomplete or inaccurate documentation, failure to provide documented care, or other deceptive acts. All medical services must be medically necessary, and the patient or resident must be eligible for and involved in the decision regarding those services. For home health services, it is crucial that all claims reflect services that are appropriately documented, reasonably necessary, and provided to patients who meet the eligibility criteria for Medicare or Medicaid home health benefits. Services must be delivered as documented, and proper certification of patient eligibility is required. For hospice services, individuals must meet specific criteria, including having less than six months to live. Providing unnecessary medical services can be considered a false claim, and failure to promptly report a false claim may result in lawsuits, fines, and other sanctions.
Discussion Points
- Review policies and procedures related to home healthcare and hospice services to ensure they are accurate and current. Update policies as needed.
- Train staff on the criteria for enrolling residents in both home healthcare and hospice programs. This includes educating nursing staff and social services on the procedures for receiving or making referrals and ensuring that all training sessions are documented. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory.
- Periodically audit to ensure that residents enrolled in home healthcare and hospice programs meet the established eligibility criteria. Verify that all services provided are appropriately documented and supported by the need for such services. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
