Health Care Fraud Scheme

Everyone Has a Responsibility to Ensure the Rules are Followed.

Less than two weeks ago it was announced that one of the largest homecare providers in the country agreed to a one-time cash settlement of $25 million in response to a Medicare investigation on hospice continuous care services. Two days ago, a Dallas physician and six others were arrested for their alleged role in a nearly $375M health care fraud scheme involving fraudulent claims for home health services.

I started this blog a couple of days ago.  One of the things I’d written was, “I don’t believe there are C-level people sitting around the executive table thinking of ideas, or ways, to ‘game’ the Medicare rules. That would be sheer craziness.  Who logically enters a discussion or process to ‘optimize’ hospice billing or hospice documentation for the purposes of committing an illegal act?”  I’m an optimist and a rule follower. I can’t conceptualize this happening, but I’m (sadly) very wrong.

On February 28, 2012 in a U.S. Department of Health & Human Services press release it was announced that a Dallas physician, office manager and five owners of Dallas-area home health care agencies were arrested in an alleged $375 million health care fraud scheme.  Dr. Jacques Roy has been charged with nine counts of substantive health care fraud and one count of conspiracy to commit health care fraud. CMS announced the suspension of an additional 78 home health agencies associated with Dr. Roy based on credible allegations of fraud against them. How did they uncover this? It was reported that sophisticated data analytics are being used to identify suspicious billing spikes. In this case, they discovered that 99% of physicians who certify home health patients signed off on 104 or fewer people. Dr. Roy certified more than 5,000.

How does a group of people get to a place where they allegedly commit a health care fraud scheme totaling nearly $325M? How are so many people involved and why does it take the sophisticated systems at HHS to discover it? Did they think they’d never be caught? Regardless of how these things happen, either in the case of the $25M settlement or the $325M scheme, everyone has a responsibility to ensure the rules are followed.  There is a responsibility to ensure that the documentation that is being completed is done so in a manner that clinicians, OBQI teams, directors and the like can solidly stand behind the decisions that were made and defend them if necessary.  As such, it’s important to use a clinical software solution that provides visiting staff for both home health and hospice agencies to be empowered to document the patient’s condition, situation and how they treated it such that should there be questions later, they can stand behind their documentation. Talk with your vendor to ensure you’re maximizing the capabilities of your point of care solution. It’s in your best interest!

Are you looking for home care software? Are you interested in point of care? Perhaps you could use some help with your homecare billing or coding? HEALTHCAREfirst has the solutions for you! Click here to contact us.