10/30/2013

1

MEDICAID HOME CARE and HOSPICE: PROGRAM INTEGRITY

NAHC ANNUAL MEETINGMichelle Martin mmartin@nahc.orgWilliam A. Dombi wad@nahc.org

COMPLIANCE: FOCUS ON HOME CARE & HOSPICE

All enforcement entities looking at home careBilling for services actually renderedg yMedical necessityTechnical compliance/documentation

High level fraud/False Claims Act investigationsOIG continues home care efforts

Medicaid home care new on the agendaPersonal care is the main focusStaff credentials including health screening a target

Hospice honeymoon is over

10/30/2013

2

Medicaid Home Care Risk AreasNew compliance efforts in Medicaid home care nationwide likely related to growth in spendingDual-eligibles (Medicare maximization)

Pre-payment conditions such as a full Medicare denialPost-payment claim by claim review with Medicare claim submissions required

Private duty nursing: pediatric and adultsF d d tiFrequency and duration

Personal care servicesHospice

Medicaid Home Care Target Areas

CLAIMS

SERVICES RENDERED

FALSE BILLINGS

STAFF CREDENTIALS

REFERRAL KICKBACKS

10/30/2013

3

TARGET: CLAIMS

UTILIZATIONAUTHORIZATION OF CARECOMPLIANCE/CONSISTENCY WITH APPROVED PLAN OF TREATMENTDOCUMENTATIONTECHNICAL REQUIREMENTSTECHNICAL REQUIREMENTS

TARGET: UTILIZATION

Data analysis to target provider utilization Ab t tt t id thAberrant patterns outside the norm

Statistical deviationPercent increase billing, payment, number visits/services

High utilization services/itemsHigh cost services/itemsHigh cost services/items

6

10/30/2013

4

F2F Oversight

ACA requires F2F on Medicaid home h lthhealthCMS yet to promulgate F2F Medicaid ruleStates may implement F2F on their own

Medicaid Personal Care

OIG audit focusNorth CarolinaNorth Carolina, http://oig.hhs.gov/oas/reports/region4/41004003.pdf ($41.71M) Audit (A-04-10-04003, June 2011)

Missing documentationServices not in accordance with plan of careNo supervisory nursing visitsNo supervisory nursing visitsNo verification caregiver qualificationsNo physician order

8

10/30/2013

5

Medicaid Personal Care

Washington State, http://oig hhs gov/oas/reports/region9/9090003http://oig.hhs.gov/oas/reports/region9/90900030.pdf Audit (A-09-09-00030, June 2011)

No timesheets supporting daily serviceBilled more hours than on timesheetsTraining deficiencies

9

Medicaid Personal CareAttendants whose qualifications were not documented, http://oig.hhs.gov/oei/reports/oei-07-08-00430.pdf - 10 State review: CA, FL, GA, IL, IA, NE, NY, OH, TN, WVNYC, http://oig.hhs.gov/oas/reports/region2/20701054.pdf Audit (A-02-07-01054, June 2009)

No medical professional exam of beneficiary before serviceNo nursing assessmentNo nursing supervisionNo physician’s order

N.Y. State, http://oig.hhs.gov/oas/reports/region2/20801005.pdf Audit (A-02-08-01005, Oct. 2010)

Same as above for NYC andNo in-service training for aideNo in-service training for aideTime with patient not documented

10

10/30/2013

6

Medicaid Hospice Risk AreasBilling for Medicaid personal care to a Medicare hospice patientM di id billi f i d it d dMedicaid billing for services and items covered under Medicaid hospice benefit

PharmaceuticalsAmbulance

State Medicaid payment reductions that reflect beneficiary contribution obligation

http://www.oig.hhs.gov/oas/reports/region1/11000004.asp.sp.OIG found that Massachusetts Medicaid did not reduce hospice payments to reflect “spend down” patients’ contribution obligation

OIG Oversight Activity

OIG 2012 Workplan (Medicaid Home Care)OIG 2012 Workplan (Medicaid Home Care)Medicaid home care worker screeningsMedicaid home health claims and CoP complianceCMS policies on Medicaid homebound requirementsHCBS: oversight of care qualityHCBS: vulnerabilities in providing servicesHCBS: State administrative costsHCBS: State administrative costsMedicaid Personal Care Services

10/30/2013

7

OIG 2013 WORKPLAN

Home Health Services—Duplicate Payments by Medicare and Medicaid (New)

“We will review Medicaid payments by States for Medicare-covered home health services to determine the extent to which both Medicare and Medicaid have paid for the same services. States are required to offer home health services to Medicaid beneficiaries who meet the States’ criteria for nursing home coverage. (Social Security Act, § 1902(a)(10)(D).) Medicaid is thecoverage. (Social Security Act, § 1902(a)(10)(D).) Medicaid is the payer of last resort, paying only after all other third-party sources have met their legal obligation to pay. (Social Security Act, §1902(a)(25).)”(OAS; W-00-13-31305; various reviews; expected issue date: FY 2014; new start)

OIG 2013 WORKPLANHome Health Services—Screenings of Health Care Workers“We will review health-screening records of Medicaid home health care workers to determine whether the workers were screened in accordance with Federal and State requirements. Examples of health screenings can include vaccinations for hepatitis and influenza. Home health agencies (HHA) provide health care services to Medicaid beneficiaries while visiting beneficiaries’ homes. HHAs must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations and with accepted standards that apply to personnel providing services within such an agency. (Social Security Act §1891(a)(5) ) The Federal requirements for home healthSecurity Act, §1891(a)(5).) The Federal requirements for home health services are found at 42 CFR §§ 440.70, 441.15, and 441.16 and at 42 CFR pt 484. Other applicable requirements are found in State and local regulations.” (OAS; W-00-11-31387; W-00-12-31387; various reviews; expected issue date: FY 2013; work in progress)

10/30/2013

8

OIG 2013 WORKPLAN

Home Health Services—Provider Compliance and Beneficiary EligibilityBeneficiary Eligibility“We will review HHA claims to determine whether providers have met applicable criteria to provide services and whether beneficiaries have met eligibility criteria. Providers must meet criteria, such as minimum number of professional staff, proper licensing and certification, review of service plans of care, and proper authorization and documentation of provided services. A doctor must determine that the beneficiary needs medical care at home and prepare a plan for that care. The care must include intermittent (not full-time) skilled nursing care and maymust include intermittent (not full time) skilled nursing care and may include physical therapy or speech-language pathology services. The standards and conditions for HHAs’ participation in Medicaid are at 42 CFR § 440.70 and 42 CFR pt. 484.” OAS; W-00-10-31304; W-00-11-31304; W-00-12-31304; various reviews; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLAN

Home Health Services—Homebound Requirements“We will review CMS policies and practices for reviewing the sectionsWe will review CMS policies and practices for reviewing the sections of Medicaid State plans related to eligibility for home health services and describe how CMS intends to enforce compliance with appropriate eligibility requirements for home health services. We will also identify the number of States that violate Federal regulations by inappropriately restricting eligibility for home health services to homebound recipients. States must ensure that the services available to any individual in a categorically or medically needy group are comparable to the services available to the entire group. (42 CFR §440.240(b).) States may not arbitrarily deny or reduce the amount, duration, or scope of a required service because of a beneficiary’s diagnosis, type of illness, or condition. (42 CFR § 440.230(c).)”(OEI; 00-00-00000; expected issue date: FY 2014; new start)

10/30/2013

9

OIG 2013 WORKPLAN

Medicaid Waivers—Quality of Care Provided Through Waiver ProgramsThrough Waiver Programs“We will determine the extent to which Medicaid home and community-based services (HCBS) beneficiaries have service plans, receive the services in their plans, and receive services from qualified providers. Pursuant to the Social Security Act, § 1915(c), States are permitted to waive certain Medicaid requirements to provide a wide range of services to persons who would otherwise receive institutional care. In addition, States offering HCBS waiver programs must provide adequate planning for services and provide those services throughadequate planning for services and provide those services through qualified providers, as well as ensure the health and welfare of beneficiaries. Prior OIG work found vulnerabilities in State systems to ensure the quality of care provided to HCBS beneficiaries. (Social Security Act, §§ 1915 (c)(1) and 1902(a)(23).)” (OEI; 02-11-00700; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLAN

Medicaid Waivers—Supported Employment Services (New)(New)“We will review Medicaid payments by States for supported employment services to determine whether such services were rendered in accordance with Federal and State requirements. With approval from CMS, States are authorized to waive certain Medicaid requirements, allowing a State to offer home and community-based services to State-specified target group(s) of Medicaid beneficiaries. (Social Security Act § 1915(c).) Supported employment helps individuals with the most significant disabilities to become competitively employed. Authorized services include vocational or job-related discovery or assessment, person-centered employment planning, job placement, training,assessment, person centered employment planning, job placement, training, and other workplace support services. (CMS Informational Bulletin, Sept. 16, 2011). Prior OIG work has identified significant unallowable Medicaid payments made by a State for supported employment services not covered under the waiver.”(OAS; W-00-12-31463; various reviews; expected issue date: FY 2013; work in progress)

10/30/2013

10

OIG 2013 WORKPLAN

Medicaid Waivers—Adult Day Health Care Services (New)(New)“We will review Medicaid payments by States for adult day care services to determine whether the payments complied with certain Federal and State requirements. Adult day health care programs provide health, therapeutic, and social services and activities to program enrollees. Beneficiaries enrolled in adult day health care programs must meet eligibility requirements, and services must be furnished in accordance with a plan of care. Medicaid allows payments for adult day health care through various authorities, including HCBSfor adult day health care through various authorities, including HCBS waivers. (Social Security Act, § 1915, and 42 CFR § 440.180.)”(OAS; W-00-12-31386; various reviews; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLAN

Medicaid Waivers—Unallowable Room and Board Costs (New)“We will determine whether selected State Medicaid agencies claimed gFederal reimbursement for unallowable room and board costs for home and community-based services (HCBS) provided pursuant the Social Security Act, § 1915(c). We will determine whether payments made by States for HCBS included the cost of room and board and the method used. Medicaid covers the cost of HCBS provided under a written plan of care to individuals in need of the services but does not allow for payment of room and board costs. (42 CFR §§ 441.301(b) and 441.310(a).) States may use various methods to pay for these services, such as a settlement process based on annual cost reports, or prospective rates with rate adjustments based on cost report data and cost trending factors.” (OAS; W-00-13-31465; various reviews; expected issue date: FY 2014; new start)

10/30/2013

11

OIG 2013 WORKPLAN

School-Based Services—Students With Special Needs“We will review Medicaid payments by States for school-based p y yservices to determine whether the costs claimed for such services are reasonable and properly allocated. Medicaid may pay for medical services provided to students with special needs pursuant to individualized education plans. (Social Security Act, § 1903(c).) Direct medical services may include physical therapy; occupational therapy; speech therapy; and nursing, personal care, psychological, counseling, and social work services. Some States use random moment time studies to develop school-based health service payment rates. Costs claimed must be reasonable and be allocated according to the benefit received. (OMB Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments.)”(OAS; W‐00‐11‐31391; W-00-12-31391; various reviews; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLAN

Community Residence Rehabilitation Services“We will review Medicaid payments for beneficiaries who reside inWe will review Medicaid payments for beneficiaries who reside in community residences for people who have mental illnesses to determine whether States improperly claimed FFP. Previous OIG work in one State found improperly claimed Medicaid reimbursement for individuals who were no longer residing in a community residence. To be allowable, costs must be authorized, or not prohibited, under State or local laws or regulations. (Office of Management and Budget (OMB) Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments, Attachment A, § C.1.c.)”(OAS; W-00-10-31087; W-00-11-31087; various reviews; expected issue date: FY 2013; work in progress)

10/30/2013

12

OIG 2013 WORKPLAN

Continuing Day Treatment Mental Health Services“We will review Medicaid payments to continuing day treatment (CDT) providers in one State to determine whether Medicaid payments by the State to CDT providers in that State are adequately supported. CDT providers render an array of services to those who have mental illnesses on a relatively long-term basis. A CDT provider bills Medicaid on the basis of the number of service hours rendered to a beneficiary. One State’s regulations require that a billing for a visit/service hour be supported by documentation indicating the nature and extent of services provided. A State commission found that more than 50 percent of the service hours billed by CDT providers could not be substantiated. We will follow up on the commission’s findings. To be allowable, costs must be authorized or not prohibited under State or local laws orcosts must be authorized, or not prohibited, under State or local laws or regulations. (Office of Management and Budget (OMB) Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments, Att. A, § C.1.c.)”(OAS; W-00-11-31128; W-00-12-31128; various reviews; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLANPersonal Care Services—Compliance With Payment Requirements“We will review Medicaid payments by States for personal care services (PCS) to determine whether States have appropriately ( ) pp p yclaimed the FFP. Medicaid covers PCS only for those who are not inpatients or residents of hospitals, nursing facilities, institutions for mental diseases, or intermediate care facilities for individuals with developmental disabilities. (Social Security Act, § 1905(a)(24).) PCS must be authorized by a physician or (at the option of the State) otherwise authorized in accordance with a plan of treatment, must be provided by someone who is qualified to render such services and who is not a member of the individual’s family, and must be furnished i h th l ti B i i J 1 2007 St tin a home or other location. Beginning January 1, 2007, States are allowed to pay individuals for self-directed personal assistance services for the elderly and disabled, including PCS that could be provided by a family member. (DRA, § 6087.)”(OAS; W-00-10-31035; W-00-11-31035; W-00-12-31035; various reviews; expected issue date: FY 2013; work in progress)

10/30/2013

13

OIG 2013 WORKPLAN

Hospice Services—Compliance With Reimbursement RequirementsRequirements“We will determine whether Medicaid payments by States for hospice services complied with Federal reimbursement requirements. Medicaid may cover hospice services for individuals with terminalillnesses. (Social Security Act, § 1905(o)(1)(A).) Hospice care provides relief of pain and other symptoms and supportive services to terminally ill persons and assistance to their families in adjusting to the patients’ illness and death. An individual, having been certified as terminally ill may elect hospice coverage and waive all rights toterminally ill, may elect hospice coverage and waive all rights to certain otherwise covered Medicaid services. (CMS’s State Medicaid Manual, Pub. 45, § 4305.) In FY 2010, Medicaid payments for hospice services totaled more than $816 million.” (OAS; W-00-11-31385; W-00-12-31385; various reviews; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLAN

State Procedures for Identifying and Collecting Third-Party Liability PaymentsThird Party Liability Payments“We will review States’ procedures for identifying and collecting third-party payments for services provided to Medicaid beneficiaries to determine the extent to which States’ efforts have improved since our last review. Many Medicaid beneficiaries may have additional health insurance through third-party sources, such as employer-sponsored health insurance. OIG work in 2006 described problems that State Medicaid agencies had in identifying and collecting third-party payments. States are to take all reasonable measures to ascertain thepayments. States are to take all reasonable measures to ascertain the legal liabilities of third parties with respect to health care items and services. (Social Security Act, § 1902(a)(25).) The DRA, § 6035, clarified the provision for entities defined as third-party payers.” (OEI; 05-11-00130; expected issue date: FY 2013; work in pro

10/30/2013

14

OIG 2013 WORKPLAN

State Compliance With the Money Follows the Person Demonstration Program (New)Person Demonstration Program (New)“We will review selected States’ compliance with the Money Follows the Person (MFP) rebalancing demonstration program. The MFP program was authorized by the Deficit Reduction Act of 2005 (DRA), §6071, and was extended by the Affordable Care Act, § 2403. The MFP program was designed to assist States in rebalancing their long-term-care systems and to help Medicaid enrollees transition from institutions to the community. The MFP program is authorized through September 30, 2016, at up to $4 billion. We will determine whetherSeptember 30, 2016, at up to $4 billion. We will determine whether States followed applicable requirements for participating in the MFP program, such as providing qualified services to eligible participants.” (OAS; W-00-12-31461; various reviews; expected issue date: FY 2013; work in progress)

OIG 2013 WORKPLAN

Medical Equipment and Supplies—Potential Savings From the Competitive Bidding Program (New)From the Competitive Bidding Program (New)Medical Equipment and Supplies—Opportunities To Reduce Medicaid Payment Rates for Selected Items (New)Medical Equipment and Supplies—Opportunities To Reduce Medicaid Payment Rates for Blood-Glucose Test Strips (New)Test Strips (New)Medical Equipment and Supplies—States’ Efforts To Control Costs for Disposable Incontinence Supplies (New)

10/30/2013

15

ENFORCEMENT ACTIVITY

Pure fraudFraud, kickbacks, false records, and moreNon-complianceDocumentation weakness

PURE FRAUD

SERVICES NOT RENDEREDAgency model

OwnerEmployeeOwner + employeeAgency + client

Individual Provider (IP) modelWorker

Personal care attendantNurse

Worker + clientClientFamily

10/30/2013

16

PURE FRAUD: Home Care Agency

Two Area Women Convicted in Home Health Services ConspiracyServices ConspiracySeptember 4, 2013http://www.justice.gov/usao/txs/1News/Releases/2013%20September/130904%20%20Ramirez%20and%20Velasquez.htmlAdmitted they created false and fraudulent timeAdmitted they created false and fraudulent time sheets for former Caring Touch employees for home health services that had not been provided and then fraudulently billed Medicaid, Evercare and Superior

PURE FRAUD: Home Care Agency

Orange Village man sentenced to two years in prison, ordered to pay $1.9 million for health

f d (J l 19 2013)care fraud (July 19, 2013)http://www.justice.gov/usao/ohn/news/2013/19julypatel.htmlOwner was aware that employee falsified documents related to health care services allegedly provided to home health patients where the services were never provided, or were provided by homewere never provided, or were provided by home health aide that had previous criminal convictions that excluded them from providing health services in people’s houses.

10/30/2013

17

PURE FRAUD: Home Care Agency

Owner of Cranford home health care company faces charges of fraudulent billing MedicaidJuly 12, 2013http://www.nj.com/union/index.ssf/2013/07/owner_of_cranford_home_health_care_company_faces_charges_of_fraudulent_billing_medicaid.htmlThe owner of Home Care Solutions was charged with seven counts of second-degree health care claims fraud and one count of third-degree Medicaid fraud, Acting Attorney General John Hoffman said in a statement State officialsGeneral John Hoffman said in a statement. State officials allege she submitted multiple requests for payment for home care aide services that were not provided, including bills for services to Medicaid beneficiaries while they were hospitalized or on vacation.

PURE FRAUD: Agency employee

State Charges 29 With Medicaid Fraud (August 1, 2013)http://www.seniorvoicealaska.com/story/2013/08/01/breakingnews/state charges 29 with medicaid fraud/200 html-news/state-charges-29-with-medicaid-fraud/200.html

On July 9, 2013, the Medicaid Fraud Control Unit in the Alaska Department of Law announced the filing of criminal charges against 29 Anchorage based personal care attendants (PCA) and Medicaid recipients.The initial review of the PCAs working for Good Faith revealed that numerous PCAs were making over $100,000 a year and one PCA made over $275,000 in two years. The alleged schemes included conduct such as billing Medicaid for PCA services while the gprovider or recipient was traveling out of the country, billing for overlapping time, billing for services not provided, and splitting funds between the PCA and Medicaid recipient for fraudulently billed services.

10/30/2013

18

PURE FRAUD: Agency and Client’s parent

PARENT OF MEDICAID RECIPIENT CONVICTED OF FEDERAL HEALTH CARE FRAUDFebruary 23, 2011y ,http://www.justice.gov/usao/lae/news/2011/2011_02_23_jo_ann_girod_verdict.htmlA resident of Marrero, LA, was convicted as charged today by a federal jury of nine counts of health care fraud, announced U. S. Attorney Jim Letten. According to evidence introduced at trial, A New Beginning of New Orleans, Inc.(ANBNO), was a Medicaid Provider located in Harvey, Louisiana that made claims for Personal Care Services it claimed to have provided to Medicaid recipients. ANBNO solicited mothers with children who had Medicaid benefits to apply for PCS. The mother to three children who were Medicaid recipients, signed forms and represented that ANBNO provided PCS services to each of her children for two hours a day everyprovided PCS services to each of her children for two hours a day every day between April, 2001 and February, 2005. Instead of providing PCS, ANBNO workers assigned to care for the children paid the parent cash kickbacks for the use of her children’s Medicaid information.

PURE FRAUD: Individual Provider—Personal Care Attendant

Home Health Aide Sentenced to Prison for Medicaid Fraud Involving Time at Casinos, Resorts July 18, 2013http://www ohioattorneygeneral gov/Media/Newshttp://www.ohioattorneygeneral.gov/Media/News-Releases/July-2013/Home-Health-Aide-Sentenced-to-Prison-for-MedicaidOhio Attorney General Mike DeWine announced that a former Cleveland-area home health aide will be going to prison for improperly billing the Ohio Department of Medicaid for more than $234,000. Franklin County Common Pleas Court Judge Kim Brown sentenced Ellanora Whiting, 39, to two years in prison. She must also pay $234,663.61 in y p p yrestitution of taxpayer dollars.Whiting pleaded guilty in June to a felony charge of Theft after an investigation by Attorney General DeWine's Medicaid Fraud Control Unit (MCFU) revealed that she billed Medicaid for time spent gambling.

10/30/2013

19

PURE FRAUD: Individual Provider—Personal Care Attendant

Man Lost Toes after Couple's Medicaid FraudMay 23, 2013http://articles ktuu com/2013 05 23/medicaid fraud 39483131http://articles.ktuu.com/2013-05-23/medicaid-fraud_39483131An Anchorage husband and wife have been sentenced for endangering the welfare of an adult, after billing Medicaid for care they didn’t provide to a diabetic man who later had two of his toes amputated. Adult Protective Services employees with the Alaska Department of Health and Social Services became aware that the Medicaid recipient was not receiving care after the recipient’s apartment manager called authorities due to the unsanitary conditions of the recipient’s apartment and his personal hygiene.

Instead of caring for the recipient, the couple simply handed the recipient their timesheets through his apartment window for him to sign in order to verify that services were being provided.

PURE FRAUD: Individual Provider---Nurse

Milwaukee nurse convicted of Medicaid fraud over phantom home health careMarch 11 2013March 11, 2013http://m.jsonline.com/197153521.htmA Milwaukee nurse who billed Medicaid for in-home care she never provided has been convicted of Medicaid fraud and theft. Yvette Harris, 50, was found guilty Friday after a five-day jury trial in Milwaukee. According to the criminal complaint, the mother of a young girl who required home health care related to a ventilator and other complex health needs interviewed Harris, but decided against hiring her toneeds interviewed Harris, but decided against hiring her to provide the medical care. But from June 2010 to April 2011, Harris billed the Wisconsin Medicaid program claiming to have provided care to the child on 136 days for a total of $32,330.41. At her sentencing May 16, Harris could receive more than six years in prison and be fined up to $35,000.

10/30/2013

20

PURE FRAUD: Individual Provider and client

Former Inmate Sentenced for Fraud on the Medicaid Home Services ProgramOctober 31, 2012,http://www.justice.gov/usao/ils/News/2012/Oct/10312012_Foreman%20Press%20Release.htmlSentenced to six (6) months confinement in the Bureau of Prisons, three (3) year’s of supervised release following his confinement, a special assessment of $100, and ordered to pay restitution in the amount of $496.65 to the State of Illinois and the Center for Medicare and Medicaid Services. Pled guilty to defrauding the Illinois Department of Human Services (DHS) Home Services Program, a Medicaid Waiver Program designed to prevent the unnecessary institutionalization of individuals who may instead be satisfactorily maintained at home at a lesser cost to the State The beneficiary of the Medicaid Waiver program admitted thatthe State. The beneficiary of the Medicaid Waiver program, admitted that he got out of jail for a one day furlough to meet with his case worker at his home outside of prison so that he could continue receiving the Home Services Program benefits. He returned to jail after being approved for the services. Medicaid continued pay for personal assistant services supposedly provided to Foreman by his girlfriend while Foreman remained in jail for several months.

PURE FRAUD: Individual Provider and family members

Folsom Family Arrested for Medicaid Fraud, Racketeering, and Cruelty (August 28, 2013)http://www ag state la us/article aspx?articleID=758&catID=2http://www.ag.state.la.us/article.aspx?articleID=758&catID=2Today Attorney General Buddy Caldwell said a criminal investigation by the Attorney General’s Medicaid Fraud Control Unit has unraveled a Folsom family’s alleged pattern of Medicaid fraud, criminal conspiracy and financial exploitation arising from more than $400,000 in Medicaid-funded care paid on behalf of a disabled relative. Three family members face a combined 24 felony charges, including racketeering, criminal conspiracies to commit g g pMedicaid fraud and filing false public records, Medicaid fraud, filing false public records, theft by fraud, forgery and money laundering in connection with a scheme to bill Louisiana’s Medicaid program for services not actually rendered.

10/30/2013

21

PURE FRAUD: Individual Provider and family members

Family committed $50K in Medicaid fraud (July 10, 2013)http://www.koin.com/2013/07/10/docs-gresham-family-committed-50k-in-medicaid-fraud/A woman and her daughter are accused of filing thousands of dollars in false Medicaid claims which they alleged went to care for a disabled family member who was, in fact, not disabled at all.Medicaid-paid homecare providers who filed more than $42,000 in monthly and bi-monthly vouchers between January 2012 and May 2013. The payments supposedly went towards the fulltime care of Vera’s elderly mother. Her daughter and granddaughter were paid nearly $3,000 a month to live with her and provide her with 24-hour care, the affidavit states.The fraud was first discovered when a state Department of Human Services worker conducted a welfare check on the client in September 2012 d f d h “ ki d i f l b t th t t ” th2012 and found her “cooking and moving freely about the apartment,” the affidavit reads. At that time, the building manager told the DHS worker that the client resided alone.Medicaid Fraud Unit investigators began to conduct undercover surveillance and found that she would fake disability during health and service assessments. They discovered that the granddaughter never came to the apartment, and the daughter only visited sporadically.

Third Party Allegations

Brooklyn Licensed Home Health Care Services Agency Pays One Million Dollars to Settle Civil Fraud Claims That it P id d U lifi d H H lth Aid t M di idProvided Unqualified Home Health Aides to Medicaid Recipients June 18, 2013http://www.justice.gov/usao/nye/pr/2013/2013jun18.htmlSettlement agreements with a Brooklyn-based licensed home health care services agency. These settlements resolve allegations that the company provided unqualified home health aides to home health agencies who in turnhome health aides to home health agencies, who in turn sent these unqualified aides into the homes of Medicaid recipients throughout New York City and then billed the Medicaid program for their services. Under the terms of the agreements, the company will pay a total of $1,000,000.

10/30/2013

22

Fraud, kickbacks, false records, and more

Falsified credentialsFalse care recordsKickbacks for referrals/enrollmentBribesClient endangerment

Fraud, kickbacks, false records, and more: Examples

State Suspends Enrollment in Adult Care Plan Amid Fraud ConcernsApril 25, 2013h // i /2013/04/26/ i / k d llhttp://www.nytimes.com/2013/04/26/nyregion/new-york-suspends-enrollment-in-long-term-care-plan.html?ref=todayspaper&_r=3&State officials have suspended enrollment in New York’s largest managed long-term care plan for frail elderly and disabled people, and investigators have begun examining the relationships between such plans, which are financed by Medicaid, and the social adult day care centers that send them new customers. Evidence that some centers had persuaded seniors to sign up with incentives like free takeout food, casino visits and cash before steering them to managed care companies eager to enroll them in plans designed for older people with long-term needs like home health care and nursing.

10/30/2013

23

Fraud, kickbacks, false records, and more: Examples

Former CEO/Owner of Home Health Care Provider Sentenced To Prison For Falsifying Records Involving a Federal AuditApril 2013http://www.justice.gov/usao/dc/news/2013/jul/13-271.htmlPled guilty to a charge of falsification of records in connection with a federal investigation. The Chief Executive Officer and owner was informed that the U.S. Department of Health and Human Services requested the physician-signed plans of care for 130 of its patients. CEO knew that the agency lacked plans of care for 62 of these 130 patients. CEO directed her employees to fraudulently create plans of care for the services that these 62 patients received, making it appear as if the documents had been created prior to the services being provided.

Fraud, kickbacks, false records, and more: Examples

EXECUTIVE DIRECTOR SENTENCED TO ALMOST 4 YEARS IN FEDERAL PRISON FOR CONSPIRACYFebruary 21, 2013http://www.justice.gov/usao/wvs/press_releases/Feb2013/attachments/022113Jamie-sentencing.htmlThe founder and executive director of a St. Albans-based in-home care business was sentenced to 46 months in federal prison for conspiracy in connection with a health care fraud investigation. She admitted that she altered and falsified records and documents of the agency. The agency specialized in providing in-home care services to the elderly and disabled under a contract with an authorized West Virginia Medicaid provider.

10/30/2013

24

Fraud, kickbacks, false records, and more: Examples

Eleven people arrested in large-Scale Medicaid fraud schemeFebruary 7, 2013http://www.justice.gov/usao/nj/Press/files/HHCH%20Health%20Care%20Arrests%20News%20Release.htmlNEWARK, N.J. – Federal and state agents this morning arrested 11 people who are charged by Complaint, along with two corporations, in connection with a large-scale scheme to defraud the Medicaid program of millions of dollars, U.S. Attorney Paul J. Fishman announced today. The Complaint also charges the owner of a home health aide business headquartered in Linden, N.J., with attempting on two occasions to hinder a state investigation by bribing a state regulator – who was working with the FBI – and with conspiring with the owner of another home health aide business in Elizabeth, N.J., to launder money.

Fraud, kickbacks, false records, and more: Examples

Friendship Home Health accused of Medicaid fraudJune 20, 2012http://www.bizjournals.com/nashville/news/2012/06/20/friendship-home-health-under-fire.htmlNashville-based Friendship Home Health is under civil investigation for allegations of Medicaid fraud, according to a complaint filed last month by the U.S. Attorneys' Office. The firm, which provides nursing services to in-home patients, is now operating under a temporary restraining order that prevents company officials from depositing or withdrawing funds. The United States alleged in its May 25 complaint that Friendship Home Health, which leases its private nursing services to Mississippi-based On-Call Staffing, orchestrated a kickback scheme that put an additional $20,000 a month into Home Health's pockets.

10/30/2013

25

Fraud, kickbacks, false records, and more: Examples

Home health care agency owner pleads guilty to aggravated identity theft related to health care fraudOctober 11 2011October 11, 2011http://www.justice.gov/usao/mn/press/oct010.pdfPled guilty to one count of aggravated identity theft. He admitted that from February 18, 2008, through December of 2010, he defrauded Medicaid by submitting false reimbursement claims for personal care services. He agreed to provide and facilitate kickback payments to the family of a Medicaid recipient who did not actually receive the personal care services for which the home care agency billed Medicaid

NON-COMPLIANCE

Provider qualificationsUnqualified caregiversUnqualified caregiversExcluded caregivers

Ineligible clientsUtilization Conformance with care planDocumentationDocumentation

Provider qualificationsService provisionClaims accuracy

10/30/2013

26

NON-COMPLIANCE: EXAMPLES

Personal Care Services: Trends, Vulnerabilities and Recommendations for ImprovementNovember, 2012http://oig.hhs.gov/reports-and-publications/portfolio/portfolio-12-12-01.pdfImproper Payments Linked to Lack of Compliance. As of August 2012, OIG has produced 23 audit and evaluation reports since 2006 focusing on PCS. Although the objectives, methodologies, and scopes of these audits and evaluations differed, in many instances OIG found that PCS payments were improper because the services: • were not provided in compliance with State requirements, • were unsupported by documentation indicating they had been rendered,were unsupported by documentation indicating they had been rendered, • were provided during periods in which the beneficiaries were in institutional stays reimbursed by Medicare or Medicaid, and/or • were provided by PCS attendants who did not meet State qualification requirements.

NON-COMPLIANCE: EXAMPLES

Inappropriate Claims for Medicaid Personal Care ServicesDecember 13, 2010http://oig.hhs.gov/oei/reports/oei-07-08-00430.pdfAttendant qualifications were undocumented for 18 percent of Medicaid PCS claims, resulting in $724 million in inappropriate payments. Eighteen percent of paid PCS claims (6.5 million) in our universe were inappropriate because attendants’ qualifications were undocumented. From September 1, 2006, through August 31, 2007, Medicaid paid approximately $724 million for these claims. The qualifications most often undocumented were background checks, age, and education.

For 2 percent of Medicaid PCS claims, respondents had no record of serving the beneficiaries. Respondents for 2 percent (552,578) of paid Medicaid PCS claims in our universe reported that they had no record of ever providing services to the beneficiaries named in the claims data. From September 1, 2006, through August 31, 2007, Medicaid paid approximately $63 million for these inappropriate claims.

10/30/2013

27

NON-COMPLIANCE: EXAMPLES

REVIEW OF MEDICAID PERSONAL CARE SERVICES CLAIMS SUBMITTED BY PROVIDERS IN NORTH CAROLINAJune 1, 2011SUMMARY OF FINDINGS

Of the 35 items that were not compliant, 8 contained more than 1 deficiency:• For 30 items, services were not in accordance with the plan of care.• For seven items there were no nursing visits for supervision• For seven items, there were no nursing visits for supervision.• For five items, there was a lack of required documentation.• For two items, there was no physician order.• For one item, the qualifications of the in-home care provider were not verified.

NON-COMPLIANCE: EXAMPLES

REVIEW OF IOWA MEDICAID PAYMENTS FOR HOME HEALTH AGENCY CLAIMSApril 27, 2010http://oig.hhs.gov/oas/reports/region7/71001081.pdfThe State agency claimed some costs for HHA services that were not in accordance with Federal or State requirements. Our review of the 100 claims in our sample showed that 7 claims had errors (1 claim had two types of errors) totaling $697 ($456 Federal share) of improper Medicaid reimbursement. The errors included 2 claims with unsupported services, 4 claims with unauthorized services, and 2 claims for which a billed service was not rendered.

10/30/2013

28

NON-COMPLIANCE: EXAMPLES

REVIEW OF PERSONAL CARE SERVICES PROVIDED BY TRI-STATE HOME HEALTH AND EQUIPMENT SERVICES, INC., IN THE DISTRICT OF COLUMBIANovember 4 2010November 4, 2010http://oig.hhs.gov/oas/reports/region3/30800207.pdf• 134 beneficiaries for whom Tri-State claimed hours of service in excess of the State plan limit but did not provide documentation that it requested or received the required authorization for the extended service and • $7,107 ($4,975 Federal share) on behalf of 14 beneficiaries for whom Tri-State claimed hours of services that were not provided.

Tri-State documented that it had submitted requests for waiver services forTri State documented that it had submitted requests for waiver services for these beneficiaries but did not have evidence to support that it had received preauthorization for services under the waiver. We also determined that the State agency did not ensure that all Tri-State’s PCAs met the District’s qualification requirements

PROGRAM INTEGRITY: OPERATIONAL IMPROVEMENTS

What is working, what is not

Time and attendanceStaff credentialingCare plan complianceService documentationPolicies and proceduresStaff training and oversightInternal auditing

10/30/2013

29

Program Integrity Policy Proposals: Options

Require credentialing of home health agency executivesRequire all Medicaid participating home care agencies to q p p g gimplement a comprehensive corporate compliance planStrengthen admission standards for new Medicaid home care agencies through probationary initial enrollment , prepayment claims review, increased initial capitalization requirements, and early-intervention oversight by surveyorsRequire electronic attendance and performance accountability monitoringInstitute a compliance survey process to assure care deliveryEstablish uniform data sets

Program Integrity ProposalsEstablish targeted systemic payment safeguards focused on abusive utilization of home care servicesCreate a joint Medicaid Home Care Benefit Program Integrity Council to provide a forum for partnering in program integrity improvements with Medicare, Medicaid, providers of services, and beneficiariesRequire criminal background checks on home care agency owners, significant financial investors, and managementEstablish authority for a self-policing compliance entity to supplement and complement federal and state oversightsupplement and complement federal and state oversightEnhance education and training of home care provider staff, regulators and their contractors to achieve uniform and consistent understanding and application of program standards

10/30/2013

30

CONCLUSION

Home care and hospice are serious compliance activity sectorsactivity sectors

MedicareMedicaid

True fraudulent conduct under prosecutionsIncreased oversight for all providers

Claims is primary focusp yExpected to continueIndustry working to improve