Posts Tagged ‘Office of Inspector General’

OIG Releases 2015 Work Plan

November 7, 2014

The Office of the Inspector General (OIG) recently released its annual work plan.  The Work Plan for 2015 specifically addresses issues for home health and hospice.

Overall, the Office of Inspector General (OIG) has identified reducing waste in Medicare Parts A and B and ensuring quality, including in nursing home, hospice care, and home- and community-based care, as top management challenges facing the Department. OIG has focused its efforts on reducing improper payments, improving quality and access, and fostering economical payment policies.

Work planning for fiscal year (FY) 2015 and beyond will consider the following:

  • Quality of care
  • Appropriate payments
  • Oversight of payment and delivery reform

Protecting an expanding Medicaid program from fraud, waste, and abuse takes on a heightened urgency as the program continues to grow in spending and in the number of people that it serves. The OIG’s continuing and new reviews of Medicaid in fiscal year (FY) 2015 address: prescription drugs; billing, payment, reimbursement, quality, and safety of home health services, community-based care, and other services, equipment, and supplies; State management of Medicaid, information system controls and security, and Medicaid managed care.

There were two issues specific to home health providers and one for Medicaid home health agencies. These topics have been part of the OIG’s previous work plans. The OIG’s plan for FY2015 for each of these areas is copied below.

Home Health

Home health prospective payment system requirements:

“We will review compliance with various aspects of the home health PPS, including the documentation required in support of the claims paid by Medicare. We will determine whether home health claims were paid in accordance with Federal laws and regulations. A prior OIG report found that one in four home health agencies (HHAs) had questionable billing. Further, CMS designated newly enrolling HHAs as high-risk providers, citing their record of fraud, waste, and abuse. Since 2010, nearly $1 billion in improper Medicare payments and fraud has been identified relating to the home health benefit. Home health services include part-time or intermittent skilled nursing care, as well as other skilled care services, such as physical, occupational, and speech therapy; medical social work; and home health aide services.” OAS; W-00-13-35501; W-00-14-35501; various reviews; expected issue date: FY 2015.

Employment of individuals with criminal convictions:

“We will determine the extent to which HHAs employed individuals with criminal convictions. We will also examine the criminal convictions of selected employees with potentially disqualifying convictions. Federal law requires that HHAs comply with all applicable State and local laws and regulations. (Social Security Act, §1891(a)(5), implemented at 42 CFR §484.12(a).) Nearly all States have laws prohibiting certain health-care-related entities from employing individuals with certain types of criminal convictions.” OEI; 07-14-00130; expected issue date: FY 2015.

Screenings of health care workers

“We will review health-screening records of Medicaid home health agency (HHA) health care workers to determine whether they were screened in accordance with Federal and State requirements. Health screenings for home health care workers include vaccinations, such as those for hepatitis and influenza. HHAs provide health care services to Medicaid beneficiaries while the home health care workers are visiting beneficiaries’ homes. HHAs must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations and with accepted standards that apply to personnel providing services within such an agency. (Social Security Act, §1891(a)(5).) The Federal requirements for home health services are found at 42 CFR §§440.70, 441.15, and 441.16 and at 42 CFR Part 484. Other applicable requirements are found in State and local regulations.” OAS; W-00-11-31387; various reviews; expected issue date: FY2015.

Ten Floridians Indicted in Medicare Home Health Fraud Scheme

April 10, 2014

HCAF strongly condemns healthcare fraud and supports the removal of bad actors from the home health industry.

Nine residents of Miami-Dade County and a resident of Hillsborough County have been indicted for their alleged participation in a $12.5 million Medicare fraud scheme.

On March 20, 2014, a federal grand jury in Miami returned a 59-count indictment charging Vicente Diaz, 39, Daniel Ocampo, 35, Elsa Capo, 71, Santiago Sepulveda, 79, Marta Curbeco, 67, Margarita Rodriguez, 72, Francisco Maysonet, 67, Pedro Peralta, 69, Amira Galan, 79, and Ana Rosa Santana, 77, for allegedly participating in a scheme to defraud Medicare by submitting false and fraudulent claims, and the payment and receipt of kickbacks in connection with a federal health care program, from approximately November 2011 to October 2013.

The allegations center on the operation of Marcialed and Sacred Health, two companies located in Miami-Dade County which were purportedly in the business of providing home health care to Medicare beneficiaries.

According to the indictment, Diaz controlled Marcialed and Sacred Health. Ocampo was for a time an officer of Sacred Health. Diaz and Ocampo offered and paid kickbacks and bribes to patient recruiters in return for referring beneficiaries to serve as patients so that Marcialed and Sacred could bill Medicare for home health services that were not medically necessary and were not provided. Curbeco, Rodriguez and Peralta solicited and accepted kickbacks and bribes in exchange for referring beneficiaries to serve as patients of Marcialed and Sacred Health. Capo, Sepulveda, Curbeco, Rodriguez, Maysonet, Peralta, Galan, and Santana are Medicare beneficiaries who solicited and accepted kickbacks in return for agreeing to serve as patients of Maricaled and Sacred Health so that the companies could bill Medicare for home health services that were not medically necessary and were not provided.

The indictment alleges that the defendants falsified, and caused to be falsified, records to document the receipt of home health services from Marcialed and Sacred Health that were not provided and were not medically necessary. Diaz and Ocampo violated Medicare rules and regulations by offering and paying kickbacks and bribes to patient recruiters in exchange for the referral of beneficiaries to Marcialed and Sacred Health. Diaz and Ocampo then caused Marcialed and Sacred Health to submit false and fraudulent claims seeking payment from Medicare for the home health services which had purportedly been provided to beneficiaries, when in truth the services had not been provided and were not medically necessary. The indictment alleges that as a result of the fraudulent claims, Diaz and Ocampo caused Medicare to pay approximately $7,809,243 to Marcialed and $4,694,834 to Sacred Health.

The indictment alleges that Diaz, Ocampo and other conspirators used the money fraudulently obtained from Medicare for their personal use and to further the fraud. The indictment seeks forfeiture of two properties and four Mercedes vehicles.

Mr. Ferrer commended the investigative efforts of U.S. Postal Inspection Service, HHS-OIG, and the FBI and was brought as part of the Medicare Fraud Strike Force. This case is being prosecuted by Assistant U.S. Attorney Eric E. Morales.

An indictment is only an accusation, and a defendant is presumed innocent unless and until proven guilty.

Two Miami Women Sentenced To Ten Years In Prison For Conspiring To Pay Healthcare Kickbacks in Home Health Fraud Scheme

December 27, 2013

Yiral Cardona, 39, of Miami, and Susan Chi, 42, of Miami, have been sentenced to ten years in prison stemming from their leadership role in a conspiracy to pay healthcare kickbacks.

At trial, Cardona and Chi were convicted on October 22, 2013 of one count of conspiracy to pay healthcare kickbacks and to defraud the United States, in violation of Title 18, United States Code, Section 371, and three counts of unlawful payment of healthcare kickbacks, in violation of Title 42, United States Code, Section 1320a-7b(b)(2)(A).

According to the evidence presented at trial and the sentencing hearing, Cardona and Chi owned Vista Home Health Services, Inc. (“Vista”), a Miami-Dade based home health agency that purportedly provided skilled nursing and home health services to Medicare beneficiaries. The defendants illegally obtained Medicare patients by paying bribes and kickbacks of at least $141,000 to patient recruiters to induce the referral of Medicare patients to Vista for home health services. Cardona and Chi billed the Medicare program for home health services that were not medically necessary and/or not provided. Between approximately May 15, 2009 and April 26, 2012, Medicare paid Vista more than $4.1 million in claims. The Court ordered the defendants to pay more than $733,000 in restitution.

Mr. Ferrer commended the investigative efforts of the FBI and HHS-OIG. This case was prosecuted by Assistant U.S. Attorneys Kevin J. Larsen and Eric Morales.

Source: OIG

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Two Patient Recruiters for Miami Home Health Companies Sentenced for Roles in $48 Million Health Care Fraud Scheme

December 13, 2013

Two patient recruiters for Miami health care companies were sentenced today for their participation in a $48 million home health Medicare fraud scheme.

Elizabeth Monteagudo, 33, of Miami, was sentenced to serve 70 months in prison, followed by three years of supervised release, and ordered to pay $3.5 million in restitution jointly and severally with co-defendants.   Cristobal Gonzalez, 39, of Miami, was sentenced to serve 46 months in prison, followed by two years of supervised release, and ordered to pay $2 million in restitution jointly and severally with co-defendants.

In September 2013, Monteagudo and Gonzalez each pleaded guilty to one count of conspiring to receive health care kickbacks.  Monteagudo also pleaded guilty to receiving kickbacks in connection with a federal health care program.

According to court documents, Monteagudo and Gonzalez were patient recruiters who worked for Caring Nurse Home Health Care Corp., and Gonzalez also worked for Good Quality Home Health Care Inc. Caring Nurse and Good Quality were Miami home health care agencies that purported to provide home health and therapy services to Medicare beneficiaries.

According to court documents, from approximately January 2009 through approximately June 2011, Monteagudo and Gonzalez would recruit patients for Caring Nurse and/or Good Quality and would solicit and receive kickbacks and bribes from the owners and operators of Caring Nurse and/or Good Quality in return for allowing the agency to bill the Medicare program on behalf of the recruited patients.  These Medicare beneficiaries were billed for home health care and therapy services that were medically unnecessary and/or not provided.

Monteagudo also admitted to her involvement with $7 million in fraudulent billings for Starlite Home Health Agency Inc., which she owned and operated.

In a related case, on Feb. 27, 2013, Rogelio Rodriguez and Raymond Aday, the owners and operators of Caring Nurse and Good Quality, were sentenced to serve 108 and 51 months in prison, respectively. Their sentencings followed their December 2012 guilty pleas each to one count of conspiring to commit health care fraud charged in an October 2012 indictment.   According to that indictment, from approximately January 2006 through June 2011, Caring Nurse and Good Quality submitted approximately $48 million in claims for home health services that were not medically necessary and/or not provided.  Medicare actually paid approximately $33 million for these fraudulent claims.

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

Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,700 defendants who collectively have falsely billed the Medicare program for more than $5.5 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), go to:www.stopmedicarefraud.gov .

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Orlando, Fla., Area Hospice to Pay $3 Million to Resolve Allegations That It Billed Medicare for Patients Not Terminally Ill

November 8, 2013

Hospice of the Comforter Inc. (HOTCI) has agreed to pay $3 million to resolve allegations that it violated the False Claims Act by submitting false claims to the Medicare program for hospice services provided to patients who were not eligible for the Medicare hospice benefit, the Justice Department announced today.  HOTCI is headquartered in Altamonte Springs, Fla., and provides hospice services to patients residing in Seminole, Osceola and Orange counties in Florida.

 

“This settlement is a result of the Justice Department’s continuing efforts to prevent the abuse of the taxpayer-funded Medicare hospice program, which is intended to provide comfort and care to terminally ill persons during the last six months of their lives,” said Assistant Attorney General for the Civil Division Stuart F. Delery.  “We will pursue those who seek to misuse this important benefit for their own enrichment.”

 

The government alleged that between December 2005 and December 2010, HOTCI engaged in practices that resulted in billing Medicare for patients who were not terminally ill.  Specifically, HOTCI allegedly directed its staff to admit all referred patients without regard to whether they were eligible for the Medicare hospice benefit, falsified medical records to make it appear that certain patients were eligible for the benefit when they were not, employed field nurses without hospice training, established procedures to limit physicians’ roles in assessing patients’ terminal status and delayed discharging patients when they became ineligible for the benefit. 

 

As part of this settlement, HOTCI has agreed to enter into a Corporate Integrity Agreement with the Inspector General of the Department of Health and Human Services that provides for procedures and reviews to be put in place to promptly detect and prevent future conduct similar to that which gave rise to the settlement.  In addition, HOTCI’s former Chief Executive Officer Robert Wilson has agreed to a three-year, voluntary exclusion from Medicare, Medicaid and other federal health care programs.

 

“This settlement represents a fair and appropriate resolution of this troubling matter,” said Acting U.S. Attorney for the Middle District of Florida A. Lee Bentley III.  “Hospice providers in our district should be on notice that our office will do what it takes to protect our citizens from this kind of misconduct.”

 

“Hospice care is a sacred trust from which no provider should fraudulently profit,” said Inspector General of the U.S. Department of Health and Human Services Daniel R. Levinson.  “Claiming tax dollars for people who are not terminally ill ?? and therefore ineligible for hospice care ?? cannot be tolerated.”

 

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $16.7 billion through False Claims Act cases, with more than $11.9 billion of that amount recovered in cases involving fraud against federal health care programs.

 

The allegations settled today arose from a lawsuit filed by a former HOTCI employee, Douglas Stone, under the qui tam, or whistleblower, provisions of the False Claims Act.  Under the act, private citizens can bring suit on behalf of the government for false claims and share in any recovery.  Stone’s share of the recovery has not been determined.

Source: OIG

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OIG Exclusions & Sanctions Listing Updated for October

November 8, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General (OIG) on November 6, 2013. The list includes physicians and other provider types in Florida.

Health care providers must be careful not to make payments to sanctioned entities or employ sanctioned individuals. No payment will be made by any federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal health care programs include Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States.

The basis for exclusion includes convictions for program-related fraud and patient abuse, licensing board actions and default on Health Education Assistance Loans.

Please compare your referring physicians, employees or vendors against the listing of excluded individuals.

Click here to access the updated OIG list.

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OIG Exclusions & Sanctions Listing Updated for October

October 11, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General on Oct. 8, 2013. The list includes physicians and other provider types in Florida. Health care providers must be careful not to make payments to sanctioned entities or employ sanctioned individuals.
To see the list, click here.

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Five Miami Residents Arrested for Alleged Roles in $48 Million Home Health Care Fraud Scheme

September 27, 2013

Five Miami residents have been charged for their alleged roles in a $48 million home health Medicare fraud scheme.

On Sept. 24, 2013, a federal grand jury in Miami returned an 11-count indictment charging Marianela Martinez, 45; Mireya Amechazurra, 49; Lissett Jo-Moure, 55; Omar Hernandez, 48; and Celia Santovenia, 49, each with one count of conspiracy to receive health care kickbacks and two counts of receiving kickbacks in connection with a Federal health care program.  Each charge carries a maximum penalty of five years in prison upon conviction.

According to the indictment, the defendants participated in a scheme involving Caring Nurse Home Health Care Corp. (Caring Nurse) and Good Quality Home Health Inc. (Good Quality), Miami home health care agencies that purported to provide home health and therapy services to Medicare beneficiaries.  The defendants allegedly referred Medicare beneficiaries to Caring Nurse and/or Good Quality in exchange for kickbacks, knowing that Caring Nurse and/or Good Quality would in turn bill Medicare for home health services purportedly rendered for the recruited Medicare beneficiaries.

An indictment is a formal accusation of criminal conduct, not evidence.  A defendant is presumed innocent unless and until convicted.

In a related case, on Feb. 27, 2013, Rogelio Rodriguez and Raymond Aday, the owners and operators of Caring Nurse and Good Quality, were sentenced to 108 and 51 months in prison, respectively.  The sentencings followed their December 2012 guilty pleas to one count each of conspiracy to commit health care fraud charged in an October 2012 indictment, which alleged that from approximately January 2006 through June 2011, Caring Nurse and Good Quality submitted approximately $48 million in claims for home health services that were not medically necessary and/or not provided.  Medicare paid approximately $33 million for those fraudulent claims.

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

Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,500 defendants who collectively have falsely billed the Medicare program for more than $5 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), go to:www.stopmedicarefraud.gov.

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OIG Exclusions & Sanctions Listing Updated for September

September 25, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General on Sep 18, 2013. The list includes physicians and other provider types in Florida. Health care providers must be careful not to make payments to sanctioned entities or employ sanctioned individuals.
To see the list, click here.

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Miami Home Health Patient Recruiter and Therapy Staffing Company Owner Plead Guilty in $7 Million Health Care Fraud Scheme

August 22, 2013

A patient recruiter and a therapy staffing company owner pleaded guilty today in connection with a $7 million health care fraud scheme involving the now defunct home health care company Anna Nursing Services Corp.

Ivan Alejo, 48, and Hugo Morales, 36, pleaded guilty before U.S. District Judge Jose E. Martinez in the Southern District of Florida to one count of conspiracy to commit health care fraud.  At sentencing, scheduled for Nov. 5, 2013, Alejo and Morales each face a maximum penalty of 10 years in prison.

Alejo worked as a patient recruiter at Anna Nursing, a home health care agency in Miami Springs, Fla., that purported to provide home health and therapy services to Medicare beneficiaries but in reality billed Medicare for expensive physical therapy and home health care services that were not medically necessary and/or were not provided.  Morales owned Professionals Therapy Staffing Services Inc., which provided therapists to Anna Nursing.

Alejo and his co-conspirators negotiated and paid kickbacks and bribes to patient recruiters in return for the recruiters providing patients to Anna Nursing for home health and therapy services that were medically unnecessary and/or not provided.  He and others also paid kickbacks and bribes to co-conspirators in doctors’ offices and clinics in exchange for home health and therapy prescriptions, medical certifications, and other documentation.  Alejo and his co-conspirators would use the prescriptions, medical certifications and other documentation to fraudulently bill the Medicare program for home health care services.

Morales and others created fictitious progress notes and other patient files indicating that therapists from Professionals Therapy had provided physical or occupational therapy services to particular Medicare beneficiaries, when in many instances those services had not been provided and/or were not medically necessary.  Morales knew the falsified documents were used to support false claims for home health care services billed to Medicare by his co-conspirators at Anna Nursing.

From approximately October 2010 through approximately April 2013, Anna Nursing was paid by Medicare approximately $7 million for fraudulent claims for home health care services that were not medically necessary and/or not provided.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $5 billion.  In addition, HHS’s Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

HCAF supports the Office of Inspector General and the Department of Justice in eliminating fraud in the home health industry. Removing these bad actors is paramount to protecting home health’s status as an upstanding player in the healthcare arena.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to:www.stopmedicarefraud.gov.

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