Home Health Sector Remains Area of Focus For Fraud Watchdogs

The federal government saw a return of nearly $1.9 billion in health care fraud settlements and judgments in 2021. Of this $1.9 billion, the Medicare Trust Funds received $1.2 billion, and the U.S. Centers for Medicare & Medicaid Services (CMS) received roughly $98.7 million.

The Health & Human Services Office of Inspector General’s (HHS-OIG) annual report, released Monday, details the distribution of funds, as well as the enforcement actions of the Department of Justice (DOJ) throughout 2021.

Overall, the federal government won or negotiated more than $5 billion in health care fraud judgments and settlements.

As far as enforcement actions, the DOJ opened 831 new criminal health care fraud investigations in 2021. Federal prosecutors filed criminal charges in 462 cases involving 741 defendants. In total, 312 defendants were convicted of health care fraud-related crimes last year.

The DOJ also opened 805 new civil health care fraud investigations and had 1,432 civil health care fraud matters pending at the end of 2021. 

The OIG’s investigations were responsible for 504 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid. They also included 669 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, as well as civil monetary penalty settlements.

Plus, almost 1,700 individuals and entities were excluded from participating in Medicare, Medicaid and other federal health care programs because of criminal convictions connected to those programs.

The report also highlighted a number of home health-related cases.

In 2019, trial evidence proved that a physician signed fraudulent home health care paperwork in order to submit false claims to Medicare. In exchange for certifying and recertifying patients for care services, the physician made home health agencies pay her an illegal kickback.

“The evidence showed she would not release the home health care paperwork until the home health care companies or their marketers paid her the kickback,” OIG wrote in the report.

In 2020, the physician received a 5-year prison sentence and was ordered to pay restitution to the tune of $9.5 million.

Another case — which took place in late 2020 and early 2021 — ended with four defendants receiving various prison sentences for their roles in a $80.4 million home health care fraud case. Specifically, it was a wire fraud and money laundering scheme.

“These individuals operated three sham home health agencies that never treated a single patient, yet billed Medicare for over $80 million in fraudulent claims, of which they received approximately $50 million,” the agency wrote. “They laundered the proceeds through dozens of shell companies. They evaded law enforcement detection for years by requiring nominee owners of the home health agencies and shell companies to permanently flee to Cuba upon the conclusion of their involvement in the scheme, beyond the jurisdiction of the United States.” 

Additionally, a residential care company and its owner agreed to pay $2.9 million to resolve civil FCA allegations that occured between March 2013 and September 2018. It had billed the Oregon Medicaid program for services not provided.

In general, the home health sector has been an area of focus for the Health Care Fraud and Abuse Control Program (HCFAC).

On top of this, experts believe the OIG’s recent audits on the hospice industry could be an indication of what’s next for home health.

“As we have been following and reporting on those hospice audits, the OIG has been looking at the home health space as well,” Bryan Nowicki said recently on a podcast episode of Hospice Insights. “They’re very similar in overall structure with what we have been working on with hospice. They’re looking for certain kinds of errors that they’ve identified as being recurring or ‘top of mind’ in the home health field.”