To view your agency’s scores on the Home Health Compare website, click here.

This information will be provided for state lawmakers next week when HCAF members come to Tallahassee for the 3rd Annual Legislative Day at the Capitol, and again in March for the annual March on Washington advocacy event.

Click here to access the Public Policy & Advocacy webpage to review the 2012 Legislative Toolkit.

The survey was conducted in December as a joint project with the National Private Duty Home Care Association. Nearly 1,500 responses from home care companies in all 50 states, the District of Columbia, U.S. Virgin Islands, and Puerto Rico were received.

The survey results show that eliminating the overtime exemption for personal care attendants and home care aides will have serious negative consequences for workers, clients/patients, and home care companies. The predominant impact on workers is the restriction in working hours triggered by the home care companies’ efforts to control costs through avoiding overtime hours. Nearly 63 percent of the respondents currently obligated to pay overtime under state law report that they restrict overtime hours. More than 86 percent of the companies that will face a new overtime requirement if the proposed rule takes effect, report that they will restrict the hours worked by staff to prevent overtime costs.

Clients/patients also face adverse impacts from a change in the law to require overtime to all personal care workers. The survey indicates that 81.8 percent of companies expect to increase their private pay billing charges with 23.7 percent anticipating a need to scale back their availability of care. These expectations are warranted as 45.2 percent of companies currently required to pay overtime have increased their charges and 10.4 percent reduced care access.

The greatest negative impact on clients/patients reported by respondents is the loss of continuity of care brought on by the need to assign multiple caregivers to control overtime costs. A common remark in this regard is that the clients are then driven into the underground economy, hiring workers “under the table” where they lost the quality control and oversight that an agency worker provides.

Over 93 percent of companies that would pace a new overtime obligation report an expectation of a moderate to significant increase in business costs. This mirrors the actual experiences of companies with a current overtime requirement where nearly 69 percent report moderate to significant business cost increases. The primary cost increases are in human resources, 67.4 percent expected/38.2 percent actual, and staff training costs, 67.9 percent expected/38.3 percent actual.

The business adjustments that companies are or will make include cutbacks on employee benefits and pay increases, withdrawal from Medicaid services, terminating live-in care, and reduction of current base pay of personal care workers.

The full survey report is available here. NAHC thanks Home Care Pulse for its extensive support in managing the survey and developing the analyses.

The survey report is just one of the advocacy actions steps underway in the effort to stop the DoL proposal. NAHC has commissioned a study by a labor economist into the overall economic impact of the proposed rule on business, workers, third-party payers such as Medicaid, and on the consumers of the care. The Small Business Administration Office of Advocacy has scheduled a formal” roundtable” that will bring DoL representatives together with affected business to discuss the projected impact of the proposed rule on small businesses. Also, NAHC continues to enlist the support of Congress for H.R. 3066, a bill that would leave the existing, 37 year-old, standards governing the exemption in place. A full discussion as to what you can do with Congress on this issue is available here along with helpful tools to get your message to Congress. Finally, NAHC and the Home Care Association of Florida will be drafting formal comments on the rule that will be made available to the membership in time to develop your own comments by the February 27 deadline.

The change is to the application of case mix weights (#4 below) based on episode ending date rather than M0090 date.

1. 2012 Average episode payment and LUPA rates are to be applied to episodes that end 1/1/12 through 12/31/12.
2. 2012 Wage index is applied to episodes that end 1/1/12 and after.
3. Case mix scoring (i.e. the grouper logic used to score clinical, functional, and service utilization to create the HHRG/HIPPS) is  to be based on the M0090 date. The 2012 revised case-mix scores, which reflect the elimination of the two hypertension codes, go into effect with episodes that have a M0090 date of 1/1/12 and after.
4. The 2012 case mix weights (i.e. the values assigned to the HHRG/HIPPS) are applied to episodes ending 1/1/12-12/31/12.

By publishing announcements about home health fraud, HCAF demonstrates its commitment to honest providers throughout the state by shining a spotlight on the dishonest providers, eager to provide hope and validation to the good and send a message to the bad actors that their days are numbered.

A Miami-area nurse pleaded guilty today for his participation in a $25 million home health Medicare fraud scheme, the Department of Justice, the FBI and the Department of Health and Human Services (HHS) announced today.

Jorge Pineiro, 42, pleaded guilty before U.S. District Judge Joan A. Lenard in Miami to one count of conspiracy to commit health care fraud. Pineiro was originally charged in a February 2011 indictment.

According to plea documents, Pineiro was a registered nurse who worked for ABC Home Health Care Inc. and Florida Home Health Care Providers Inc., two Miami home health care agencies that purported to provide home health and therapy services to Medicare beneficiaries. Pineiro and his co-conspirators operated ABC and Florida Home Health for the purpose of billing Medicare for expensive services that were not medically necessary and/or were never provided. The medically unnecessary services were prescribed by doctors, including, but not limited to, Pineiro’s co-defendant, Dr. Jose Nunez.

According to court documents, beginning in approximately June 2008, and continuing until approximately March 2009, Pineiro and his co-defendant nurses falsified patient files for Medicare beneficiaries to make it appear that they qualified for home health care and therapy services. Pineiro knew that the beneficiaries did not actually qualify for and did not receive the services. Pineiro and his co-defendant nurses described in nursing notes and patient files symptoms that were non-existent, such as tremors, impaired vision, weak grip and inability to walk without assistance. They included these symptoms to make it appear that the patients were unable to self-inject insulin and were homebound, thus appearing to qualify for home health care benefits under Medicare.

Pineiro admitted that he knew these files were falsified so that Medicare could be billed for medically unnecessary therapy and home health-related services. As a result of Pineiro’s participation in the illegal scheme, the Medicare program was billed approximately $118,000 for purported home health care services that were not medically necessary and/or were never provided.

Pineiro also recruited Medicare beneficiaries who allowed Florida Home Health to bill Medicare for services that were medically unnecessary and/or never provided. Pineiro solicited and received kickbacks and bribes from the owners and operators of Florida Home Health in return for allowing the agency to bill Medicare on behalf of the patients he recruited. The patients that Pineiro recruited did not qualify for the services that were billed to the Medicare program. Pineiro knew that the patient files for his recruited patients were falsified to make it appear that the patients qualified for services from Florida Home Health.

Eighteen co-defendants, including Nunez, Licet Diaz and Lisandra Alonso have pleaded guilty for their roles in the fraud scheme. Nunez, Diaz and Alonso were sentenced to 40 months, 87 months and 78 months in prison, respectively. Two remaining defendants, Dr. Francisco Gonzalez and Odalys Alvarez-Medina, are scheduled for trial on Feb. 14, 2012. An indictment is merely a charge, and defendants are presumed innocent until proven guilty.

Sentencing for Pineiro has been scheduled for April 9, 2012.

The charge of conspiracy to commit health care fraud carries a maximum prison sentence of 10 years. The defendant also faces fines and supervised release, as well as forfeiture of any property or proceeds derived from his criminal activities.

Today’s guilty plea was announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; John V. Gillies, Special Agent-in-Charge of the FBI’s Miami field office; and Special Agent-in-Charge Christopher Dennis of the HHS Office of Inspector General (HHS-OIG), Office of Investigations Miami office.

This case is being prosecuted by Trial Attorney Joseph S. Beemsterboer of the Criminal Division’s Fraud Section. The case was investigated by the FBI and HHS-OIG, and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Miami.

Since their inception in March 2007, strike force operations in nine locations have obtained indictments of more than 1,160 individuals who collectively have falsely billed the Medicare program for more than $2.9 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), click here.

The data shows state-by-state reimbursement, number of patients, visits, average reimbursement and average visits per patients.

The national average:

• Total Reimbursement: $19,533,203,558
• Patients: 3,452,459
• Visits: 124,698,461
• Average Reimbursement Per Patient: $5,691
• Average Visits Per Patient: 36

For Florida:

• Total Reimbursement: $2,278,311,770 (2nd in the nation behind TX)
• Patients: 356,502 (2nd behind TX)
• Visits: 16,877,067 (2nd behind TX)
• Average Reimbursement Per Patient: $6,391 (6th)
• Average Visits Per Patient: 47 (5th)

• ACO professionals, i.e. physicians in group practice arrangements
• Networks of individual practices of ACO professionals
• Partnerships or joints venture arrangements between hospitals and ACO professionals
• Hospitals employing ACO professionals
• Such other groups of providers of services and suppliers as the Secretary of the U.S. Department of Health and Human Services (HHS) determines appropriate [Emphasis added].

It is also important for post-acute providers to know that Section 425.20 of final regulations published by the Centers for Medicare and Medicaid Services (CMS), which govern the establishment and operations of ACOs, defines “participant” as:

…an individual or group of ACO provider(s)/supplier(s), that is identified by a Medicare-enrolled TIN, that alone or together with one or more other ACO participants comprise(s) an ACO, and that is included on the list of ACO participants that is required under Section 425.204(c)(5).

The final regulations go on to define ACO providers and suppliers as follows:

ACO provider/supplier means an individual or entity that–

1. Is a provider (as defined at Section 400.202 of this chapter) or a supplier (as defined at Section 400.202 of this chapter);
2. Is enrolled in Medicare;
3. Bills for items and services it furnished to Medicare fee-for-service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare regulations; and
4. Is included on the list of ACO providers/suppliers that is required under Section 425.204(c)(5).

The commentary to the final regulations governing ACOs makes it even clearer that post-acute providers can participate in ACOs:

We do not believe that we should be prescriptive in setting any requirements for the number, types and location of providers/suppliers that are included as ACO participants…In addition, any Medicare enrolled entities not specified in the statutory definition of eligible entities in Section 1899(b)(1)(A)-(D) of the Act can participate in the Shared Savings Program as ACO participants by joining an ACO containing one or more of the organizations eligible to form an ACO.

The commentary also states that ACO participants are defined as any Medicare-enrolled provider or supplier, including pharmacists.

Consequently, based upon the statute, the final regulations, and commentary to the final regulations, it is clear that post-acute providers may join doctors to form ACOs.

This material is provided to HCAF by Elizabeth E. Hogue, Esq. Contact by phone at (877) 871-4062, fax at (877) 871-9739 or email at elizabethhogue@elizabethhogue.net.

© 2010 Elizabeth E. Hogue, Esq.  All rights reserved. No portion of these materials may be reproduced in any form without the advance written permission of the author.

The deadline for submitting the exemption request is at 11:59 PM Eastern Time on Saturday, January 21, 2012. Click here to submit the form online.

As announced in the 2011 Home Health Prospective System Payment Update Final Rule published in the Federal Register on November 17, 2010, Medicare-certified home health agencies that served 59 or fewer unduplicated patients between April 1, 2010 and March 31, 2011 who met survey eligibility criteria may request an exemption from participating in the Home Health Care CAHPS Survey for the CY 2013 APU.

For more information about the HHCAHPS Survey, contact the HHCAHPS Survey Coordination Team via email at hhcahps@rti.org or call toll-free at (866) 354-0985.