Home Health Agency Continues Legal Fight for Lost Profits

New Vision Home Heathcare, Inc., a home health care agency based in Southfield, Michigan, is taking on health insurance and managed care giant Anthem in a Medicare billing suit that seeks $20 million in lost profits.

Anthem, the largest for-profit managed health care company in the Blue Cross and Blue Shield Association, used its subsidiary, Medicare program safeguard contractor TrustSolutions, to audit the provider. New Vision was ultimately found to have been overpaid, however, the home health agency has been fighting back for several years, claiming it has lost more than $20 million in potential profits and spent more than $400,000 on legal fees in the appeals process.

In its initial court claim filed in 2016, New Vision alleges TrustSolutions was in violation of Medicare policies in order to maximize overpayments and then gain contracts with Medicare, including contracts as a CMS Recovery
Audit Contractor.

New Vision is asking that no less than $20 million in damages be paid by Anthem.

Most recently, the home health agency has requested that a Michigan federal judge disqualify the U.S. attorney representing Anthem because it does not believe the government should provide free defense. Southfield, Michigan-based New Vision filed a motion on August 23 to remove the U.S. attorney because the government is not a party to this suit and has not filed a motion to intervene. Furthermore, the motion alleges that Anthem has acted “intentionally and with malice to harm the Plaintiffs.”

In December 2006, TrustSolutions determined that NewVision had been overpaid by approximately $670,000, and then extrapolated this sum to $4.15 million owed for the entire scope of New Vision’s claims. National Government Services then demanded that New Vision pay that sum.

New Vision pointed out in a claim filed in September 2016 that TrustSolutions did not produce sufficient evidence for the actual and extrapolated overpayment demands, and included claims outside the universe of claims for review.

“As a result of the postpayment audit, in or about December 2010, New Vision had terminated nearly all of its employees as it no longer had the financial ability to maintain payroll, New Vision had lost nearly all of its customers and New Vision had lost the overwhelming majority of its referring providers,” the agency stated in its claim.

New Vision filed an appeal, but the overpayment decision was upheld.

Then, Administrative Law Judge James S. O’Leary reviewed the case in 2011 and overturned TrustSolutions’ determination.

The case was appealed to the Departmental Appeals Board in 2013, and was again overturned by ALJ O’Leary.

With the latest request to disqualify Anthem’s defense, New Vision is continuing the fight against an audit process stemming from roughly a decade ago.

New Vision did not respond to a request for comment by press time. Anthem declined to comment.

Written by Elizabeth Jakaitis