The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has expressed the view that home health agencies (HHAs) are considered to be particularly vulnerable to fraud, waste and abuse. The Centers for Medicare & Medicaid Services (CMS) designated newly enrolling HHAs as high-risk providers in March 2011, 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. This update looks at several recent developments in home health arena.

Home Health Enrollment Moratoria

CMS recently announced new temporary moratoria on the enrollment of home health agencies in four metropolitan areas – Fort Lauderdale, Detroit, Dallas and Houston. CMS also extended for six months the current enrollment moratoria of home health agencies in Chicago and Miami. Existing providers can continue to deliver and bill for services, but no new applications will be approved in these areas. CMS stated this demonstrates its movement beyond the "pay and chase" model to fraud prevention in areas of known risk.

OIG Work Plan

OIG has released its Work Plan for fiscal year 2014 which outlines OIG's current focus areas and states the primary objectives of each project. There are several home health care focus areas.

Home health prospective payment system requirements

OIG will review compliance with various aspects of the home health prospective payment system (PPS), including the documentation required in support of claims paid by Medicare. OIG will determine whether home health claims were paid in accordance with Federal laws and regulations. A prior OIG report found that one in four HHAs had questionable billing.

Employment of individuals with criminal convictions

OIG will determine the extent to which HHAs are complying with State requirements for conducting criminal background checks on HHA applicants and employees. A previous OIG review found that 92 percent of nursing homes employed at least one individual with at least one criminal conviction; however, this review could not determine whether the nursing home employee should have been disqualified from working in nursing homes because OIG did not have access to detailed information on the nature of the employees' crimes. Federal law requires that HHAs comply with all applicable State and local laws and regulations. Nearly all States have laws prohibiting certain healthcare related entities from employing individuals with prohibited criminal convictions.

Provider and beneficiary eligibility

OIG will review HHA claims to State Medicaid programs to determine whether the billing providers met applicable criteria to provide home health services to Medicaid beneficiaries. OIG will also determine whether the beneficiaries met the criteria to receive such services. Medicaid home health services providers must meet standards and conditions of participation, many of which relate to quality of care and safety of beneficiaries, such as a minimum number of professional staff, proper licensing and certification, review of service plans of care, and proper authorization and documentation of provided services.

Screening of health care workers

OIG will review health screening records of Medicaid 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 must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations, and accepted standards that apply to personnel providing services within such an agency.

Examples of Recent Enforcement Actions

Richmond, Texas. On January 23, 2014, Stella Maduka, the operator and director of nursing of a home health agency, was arrested in connection with a Medicare fraud scheme and a conspiracy to structure bank withdrawals. According to the indictment, Ms. Maduka used a Texas-based billing service to bill Medicare for home health services that were never provided and, in many cases, not medically necessary. She also created phony medical records to perpetrate the healthcare fraud.

Detroit, Michigan. On January 24, 2014, Chiradeep Gupta, a physical therapist and part-owner of All American, a home health company, was found guilty of conspiracy to commit health care fraud and money laundering. The evidence showed that Gupta and his co-conspirators caused the submission of false and fraudulent claims to Medicare through two HHAs in the greater Detroit area. Gupta was sentenced to serve 120 months in prison, three years of supervised release, and was ordered to pay more than $10 million in restitution, jointly and severally with his co-defendants.