Posts Tagged ‘OIG’

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.

Office Worker Pleads Guilty in Miami to Role in $7 Million Health Care Fraud Scheme

June 20, 2014

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

An office worker pleaded guilty today in connection with a health care fraud scheme involving Anna Nursing Services Corp. (Anna Nursing), a defunct home health care company.

Lizette Garcia, 37, of Miami, Florida, pleaded guilty before U.S. District Judge Joan A. Lenard in the Southern District of Florida to one count of payment of health care kickbacks. Sentencing is scheduled for August 27, 2014.

Garcia was an office worker at Anna Nursing, a Miami home health care agency that purported to provide home health and therapy services to Medicare beneficiaries. According to court documents, Anna Nursing was operated for the purpose of billing the Medicare Program for, among other things, expensive physical therapy and home health care services that were medically unnecessary and/or were not provided.

On behalf of the owners and operators of Anna Nursing, Garcia paid kickbacks and bribes to patient recruiters in return for the recruiters providing patients to Anna Nursing for home health care and therapy services that were medically unnecessary and/or were not provided. Anna Nursing then billed the Medicare program on behalf of the recruited patients, which Garcia knew was in violation of federal criminal laws.

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 medically unnecessary and/or were not provided.

The case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the 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 Trial Attorneys A. Brendan Stewart and Anne McNamara of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,900 defendants who have collectively billed the Medicare program for more than $6 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, has removed over 17,000 providers from the Medicare program since 2011.

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

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.

OIG Study on Face-to-Face Recommendations to CMS: Standardized Form, Physician Education, Increased Oversight

April 10, 2014

The Office of Inspector General has published a study on the Medicare Home Health Face-to-Face (F2F) documentation requirement which highlights several solutions home care providers have suggested to improve compliance.

The study looked at 644 F2F encounter documents to analyze to what extent the documents confirmed encounters and contained the required elements as set out by CMS. The study sought to do three things:

  1. Determine the extent to which physicians who certified home health care documented the face-to-face encounters,
  2. Describe the nature of face-to-face documentation, and
  3.  Assess CMS’s oversight of the face-to-face requirement.

In addition, OIG interviewed the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to describe how they ensure that home health agencies met the face-to-face encounter requirements. The Office also reviewed guidance documents and policies from CMS or the HH MACs about monitoring the face-to-face requirement.

Read more in the Member’s Only section of HCAF’s website

Want access to this content? Join the premier organization representing the home health industry in Florida! The Home Care Association of Florida represents over 700 Florida home health care providers and vendors to the home care industry. HCAF strives to be the foremost resource and advocate for Florida’s home care industry and the patients our members serve. The Association is an active voice which continually interacts with state and federal lawmakers, regulatory agencies and fiscal intermediaries to interpret, challenge or support regulations that affect the home health care industry. We can help you stay in the race and get ahead of the pack!

Medical Clinic Owner and Other Patient Recruiters Sentenced for Roles in $8 Million Health Care Fraud Scheme

March 21, 2014

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

Several patient recruiters, including a medical clinic owner, were sentenced today for their participation in a health care fraud scheme involving Flores Home Health Care Inc., a defunct home health care company.

Lerida Labrada, 59; Mayra Flores, 49; and German Martinez, 36, all of Miami, were sentenced by U.S. District Judge Ursula Ungaro of the Southern District of Florida to serve 37 months, 24 months, and 24 months in prison, respectively.   In addition to their prison terms, all of the defendants were sentenced to three years of supervised release and ordered to pay between $200,000 and $400,000 in restitution.

On Jan. 7, 2014, Labrada pleaded guilty to conspiracy to commit health care fraud, and Flores and Martinez pleaded guilty to conspiracy to defraud the United States and receive health care kickbacks.

According to court documents, the defendants worked as patient recruiters for the owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries.   Labrada also owned and operated a Miami medical clinic that provided fraudulent prescriptions to patient recruiters and to the owners and operators of Flores Home Health.

The defendants would recruit patients for Flores Home Health and would solicit and receive kickbacks and bribes from the owners and operators of Flores Home Health in return for allowing the company to bill the Medicare program on behalf of the recruited Medicare patients.   These Medicare beneficiaries were billed for home health care and therapy services that were not medically necessary and/or were not provided.

From approximately October 2009 through approximately June 2012, Flores Home Health was paid approximately $8 million by Medicare for fraudulent claims for home health services.

The case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the 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 Trial Attorney A. Brendan Stewart of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Source: OIG

OIG Exclusions & Sanctions Listing Updated for November

December 12, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General (OIG) on December 10th, 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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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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