The home health sector remains a focus for fraud watchers

The federal government saw a return of nearly $1.9 billion in health care fraud settlements and judgments in 2021. Of that $1.9 billion, Medicare trust funds received $1.2 billion, and the U.S. Centers for Medicare & Medicaid Services (CMS) received approximately $98.7 million.

The Office of Health and Human Services Inspector General’s (HHS-OIG) annual report released Monday details the Department of Justice’s (DOJ) funding allocations and enforcement actions in 2021.

In all, the federal government has won or settled more than $5 billion in health care fraud judgments and settlements.

In terms of enforcement actions, the Department of Justice opened 831 new criminal investigations into health care fraud in 2021. Federal prosecutors filed criminal charges in 462 cases involving 741 defendants. A total of 312 defendants were convicted of health care fraud crimes last year.

The DOJ also opened 805 new civilian health care fraud investigations and had 1,432 pending civilian health care fraud cases at the end of 2021.

OIG investigations are responsible for 504 criminal actions against individuals or entities that have engaged in crimes related to Medicare and Medicaid. They also include 669 civil cases involving false claims and unjust enrichment cases filed in federal district court, as well as civil settlements for monetary penalties.

In addition, nearly 1,700 individuals and organizations were disqualified from participating in Medicare, Medicaid, and other federal health care programs because of criminal convictions related to those programs.

The report also highlights a number of cases related to home health.

In 2019, court evidence proved that a doctor signed fraudulent home health documents to submit false claims to Medicare. In exchange for certifying and recertifying patients for medical services, the doctor had the home health agencies pay her illegal bribes.

“The evidence shows that she will not release the home health records until the home health companies or their vendors pay her back,” the OIG wrote in the report.

In 2020, the doctor received a 5-year prison sentence and was ordered to pay $9.5 million in restitution.

Another case — which took place in late 2020 and early 2021 — ended with four defendants receiving varying prison terms for their roles in an $80.4 million home health care fraud case. Specifically, it was a wire fraud and money laundering scheme.

“These individuals operated three bogus home health agencies that never treated a single patient, yet billed Medicare for over $80 million in fraudulent claims, of which they received approximately $50 million,” the agency wrote. “They laundered the proceeds through dozens of shell companies. They eluded law enforcement detection for years by requiring the nominee owners of home health agencies and shell companies to flee permanently to Cuba after their involvement in the scheme ended, outside of United States jurisdiction.

Additionally, a residential care company and its owner agreed to pay $2.9 million to resolve FCA civil charges that arose between March 2013 and September 2018. It billed the Oregon Medicaid program for services not provided.

Overall, the home health care sector has been an area of ​​focus for the Health Care Fraud and Abuse Control Program (HCFAC).

On top of that, experts believe the OIG’s recent audits of the hospice industry may be an indication of what’s next for home health.

“As we’ve been monitoring and reporting on these hospice audits, the OIG has been looking at home health care as well,” Brian Nowitzki said recently on a Hospice Insights podcast episode. “They are very similar in overall structure to what we are working on with the hospice. They’re looking for certain types of errors that they’ve identified as recurring or ‘hot spots’ in home health.”

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