Over the past few weeks, government officials have seemingly restarted their aggressive oversight of Medicare-certified home health agencies.
For much of 2020, government watchdogs took a measured approach to health care oversight and enforcement, allowing operators to focus their efforts on COVID-19 mitigation instead of paperwork and compliance. But multiple settlements and charges have been made recently.
On Friday, for example, Massachusetts Attorney General Maura Healey announced that her office reached a $10 million settlement with a Lawrence-based home health care company and its owner to resolve allegations that they falsely billed MassHealth for unauthorized services.
Under the terms of the settlement, Maestro-Connections Health Systems LLC and its CEO will pay $10 million to resolve allegations that — from January 2014 through August 2019 — the provider knowingly submitted false claims to MassHealth and the state’s managed care entities for home health services that had not been appropriately authorized by a physician.
Maestro has locations in Lawrence, Auburn, Athol, Framingham, Taunton, Holyoke and Lynn, according to the attorney general’s office.
“Companies like Maestro that defraud MassHealth take vital resources away from the program and the people who need them most,” Healey said in a statement. “Since 2016, my office has recovered $40 million for MassHealth by combating fraud, waste and abuse in the home health industry. Our work continues to ensure health care dollars are spent appropriately.”
To bill MassHealth for home health services, a provider must ensure that the member’s physician has reviewed and signed a plan of care certifying that home health services are medically necessary. Home health agencies are required to maintain these records for at least six years after the medical services are provided and claims have been presented for payment.
Healey’s team alleged that Maestro billed for services for which it did not have valid, signed plans of care certifying that those services were medically necessary.
In addition to the financial payment, the settlement includes a requirement that Maestro not resume providing services to MassHealth members until it has hired an independent compliance monitor to oversee a three-year compliance program. That program must include updated policies and procedures, new training for staff, and yearly audits conducted by the monitor, according to the attorney general.
Maestro and its CEO previously agreed to pay more than $1 million in restitution and penalties after failing to pay overtime to more than 600 home health aides and failing to keep accurate payroll records.
In October 2020, Altranais Home Care of Lowell similarly paid $3.1 million to resolve allegations that it falsely billed MassHealth for unauthorized services.
The attorney general’s Medicaid Fraud Division recovered more than $45 million for MassHealth in federal fiscal year 2020. Since 2016, MassHealth spending on home health services has decreased by more than 50%.
The news out of MAssachusetts is not the only oversight development from the past week.
On Dec. 15, U.S. Attorney Ryan K. Patrick announced that two Houston, Texas-area home health agency owners were set to appear in federal court on charges they fraudulently billed more than $10 million to Medicare.
Allegations against the owners, which co-owned SierCam Healthcare Services LLC, claim that they billed Medicare for home health services that were not medically necessary and often not provided as billed to Medicare from 2012 to 2020. The charges also allege the owners paid SierCam patients to sign up for medically unnecessary home health services and provided free transportation, covering the co-payments and other fees at doctor’s office visits “to facilitate their health care fraud scheme.”
Additionally, the owners allegedly created “phony medical records” to make it appear the services met Medicare’s criteria for reimbursement, according to the indictment from Patrick’s office.
If convicted of conspiracy to commit health care fraud and related offenses, the owners could face a sentence of 10 years in federal prison and a maximum $250,000 fine. If convicted of conspiracy to pay and receive health care kickbacks, they could also face up to five years in federal prison and a possible $25,000 maximum fine.