Home Health & Hospice Week

If you're wondering how much incentive regulators have to monitor your compliance, look no further than the HHS Office of Inspector General's latest semiannual report to Congress.

In the first half of fiscal year 2009, the OIG generated $2.4 billion in recoveries from providers engaged in fraud and abuse, the watchdog agency says. "These recoveries reflect our dedicated efforts to reduce fraud, waste, and abuse in HHS programs," Inspector General Daniel Levinson says in a release.And providers should expect the scrutiny to only get worse under the Obama administration.

"We will continue to employ all of our audit, evaluation, investigation, and legal tools ... to accomplish this vital and expanding mission," Levinson adds.

In addition to home health agency and hospice cases (see Eli's HCW, Vol. XVIII, No. 22, p. 174), the OIG semiannual report profiles the scheme of two Florida durable medical equipment billing company owners who ended up in prison.

All Med Billing Corp. and owners Abner and Mabel Diaz submitted claims to Medicare on behalf of suppliers for equipment that had not been ordered by physicians or delivered to the beneficiaries as claimed, the OIG says. "All Med facilitated the fraudulent billings by assisting in the concealment of the true owners of the DME companies, forging prescriptions, forging certificates of medical necessity, improperly acquiring the identities of Medicare beneficiaries, and directing the DME companies to use certain billing codes."

The Diazes were each sentenced to 14 years in prison and ordered to repay $126 million. Another All Med employee, Suleidy Cano, was sentenced to 11 years in prison for identify theft and fraud.

The full report is online at www.oig.hhs.gov/publications/docs/semiannual/2009/semiannual_spring2009.pdf.

• Watch out -- your employee liability may extend further than you think. A Texas state court has awarded former AmeriCare Home Health Services employee Andrea Davila $1.7 million for injuries she suffered in a 2005 accident while driving to a patient's home, reports Action 4 News in Harlingen, Texas. "Davila's attorneys argued that she was forced to travel in unsafe areas to ensure a timely delivery of health care to certain patients," the news station says.

An attorney procedural error contributed to the loss, AmeriCare Nursing Administrator Mario Garza says in a statement released to Action 4 News.

The San Juan, PR agency will appeal the ruling.

• Hospices served by regional home health intermediary Cahaba GBA will finally start seeing their money from the wage index restoration signed into law in February in the stimulus bill (see Eli's HCW, Vol. XVIII, No. 8, p. 58).

On April 6, the Medicare claims system started paying hospices without the budget neutrality adjustment factor (BNAF) phase-out originally set for 2009. But the law required the delay of the BNAF phase-out for all of the fiscal year.

On June 17, Cahaba began adjusting claims with dates of service after Oct. 1, 2008 but paid at the lower rate before April 6. "Claims being adjusted as a result of this instruction can be identified by the type of bill '8XI' and 'CR6418' in the 'Remarks' field on Page 04," Cahaba explains in an e-mail to providers.

The Centers for Medicare & Medicaid Services gave contractors six months from the April system update to reprocess the affected claims, Cahaba notes in its June newsletter for providers.

• If you're looking for a little help, you may want to check out the newest resource from new HH MAC NHIC.

Home Health Medicare Administrative Contractor National Health Insurance Corp., which took over from National Government Services, is making available new "job aids" on a variety of topics ranging from counting episodes to ADRs to hospice physician billing, it says in an e-mail to providers.

The aids are at www.medicarenhic.com/RHHI/RHHI_publications.shtml.

• When CMS announced that providers could get bonuses for demonstrating "meaningful use" of certified electronic health records, a firestorm erupted regarding what that term meant. CMS aims to quell any confusion following a recent meeting where the Health Information Technology (HIT) committee discussed several potential definitions of the term.

CMS intends to issue a proposed rule regarding its "meaningful use" definition later this year. In the meantime, you can submit your comments on the HIT's suggested definitions.

To read the definitions and submit your comments (which are due by June 26), visit CMS's new Web site for HIT at www.cms.hhs.gov/Recovery/11_HealthIT.asp. You can also check out the general HHS HIT site at http://healthit.hhs.gov.

• CMS has issued a new set of marching orders for medical review of DME, and you'd be wise to make sure your claims will pass muster under them.

In June 12 Transmittal No. 293 (CR 6468), CMS expands and clarifies instructions for reviewing medical necessity, DME accessories, repairs, and maintenance.

For example: When a local coverage decision (LCD) doesn't specify how far back in the patient's record to look for medical necessity documentation, it is up to the reviewer's discretion to set the look-back period, CMS says. "When deciding how far back to look, the reviewer's primary consideration shall be the likelihood that the beneficiary's condition or treatment has changed significantly enough to impact the reasonable and necessary assessment for the item," the transmittal notes.

The 15-page transmittal is at www.cms.hhs.gov/transmittals/downloads/R293PI.pdf.

• A 72-year-old physician making home visits has been sentenced to three years in prison for his part in a fraudulent Medicare billing scheme. Dr. James Ellegood in DeSoto, Mo. received the prison term and an order to pay $983,000 in restitution for submitting claims to Medicare on behalf of another physician in the practice who was excluded from Medicare, the U.S. Attorney for the Eastern District of Missouri says in a release.

Ellegood and his practice, Missouri Physician Home Services Inc., submitted claims falsely representing that he provided home visits when he was actually out of the country in the Bahamas and Mexico, prosecutors say. Coworker Dr. Rajitha Goli furnished the services, even though she was excluded from Medicare after a 2002 federal felony conviction for fraud, the release says.

PHS paid Goli by funneling money through two companies owned by relatives of Goli's and Ellegood's wife -- Hanford Nuclear Services Inc. in West Plains, Mo. and medical consulting company Arogya Inc. of Durham, N.C. The companies each received three years' probation and a $50,000 fine. Ellegood's wife Wynsleen received three years' probation and fines and restitution of about $5,500. Goli is awaiting sentencing.

• The public is taking notice of the impact an Obama administration regulatory interpretation could have on the elderly.

Department of Labor Secretary Hilda Solis has indicated the administration will reconsider whether to allow the companionship services exemption for personal care service aides in the home (see Eli's HCW, Vol. XVIII, No. 22, p. 170).

The exemption means aides don't have to receive minimum wage and overtime pay under the federal Fair Labor Standards Act.

If the current policy is revised, "health aides may be able to receive overtime for the first time,but seniors who receive the aid of health aides may not be able to afford them," notes the El Paso Times in an article highlighting the issue.

"In the coming years, the need for home health-care services will significantly increase," Rep. Silvestre Reyes (D-Texas) told the paper in a statement. "This is an issue that Secretary Solis will need to weigh carefully in the near term."

"If this ruling is reversed, the effect of this will be twofold," says attorney Peter Panken with Epstein, Becker and Green. "One, it will force a number of people into nursing homes because they can't afford the services. The second thing ... is it will raise the cost of Medicaid costs to the states," says Panken, a board member of Fedcap, a New York City nonprofit that provides home health aide services.

• National chain Gentiva Health Services Inc. has purchased Mid-State Home Health based in Alexandria, La. for undisclosed terms. Gentiva calls Mid-State "one of central Louisiana's top-three home healthcare providers" in a release about the acquisition. Gentiva doesn't currently provide services in Mid-State's 11-parish operating area, but operates in an adjacent area, the Melville, N.Y.-based company says.