Healthcare Fraud and Abuse is an ever growing problem. The Federal government has taken several steps in its enforcement efforts to cut down on health care fraud. It is estimated that health care fraud costs the United States about $80 billion per year. And it continues to rise in an alarming manner, as total U.S. health care spending continues to rise, currently topping $2.7 trillion.
In the last year, spending on home health care has increased over 5 percent from previous years. Since 2000, the senior population has increased by 15.1% versus 9.7% for the population as a whole. According to the 2014 FBI press release, these trends led to Medicare reimbursements for home-based care totaling $18.4 billion in 2011 and state Medicaid program reimbursements of $12.7 billion for beneficiaries’ personal-care services. According to the Centers for Medicare & Medicaid Services (CMS), approximately 12 million individuals receive in-home care, much of which is provided by more than 11,600 Medicare-certified home health agencies.
In the past year, federal and state law enforcement officials have increased their efforts in combatting fraud and abuse in the home health industry. This has included targeting providers referring patients for home care services, owners of home care agencies, nurse staffing agencies, and personal care aides across the country. One of the largest enforcement efforts this year has been in the Washington, DC area, culminating in the arrest of over 20 individuals accused of fraudulently billing the District of Columbia’s Medicaid program. Similarly, in Dallas, Texas, federal indictments were handed down against hundreds of home health agencies accused of Medicare Fraud that was mastered-minded by a single physician. As noted in the indictment, the agencies wrote “visit notes to make it appear that they provided skilled nursing to the Recruited Beneficiaries when no skilled nursing was provided.”
Because fraud and abuse enforcement by both Federal and State agencies is increasing, effective compliance programs for home health companies are needed to better distance the home health company from the fraud activities. At minimum, home health care agency’s compliance programs should include:
- The development and distribution of written standards of conduct, as well as written policies and procedures that promote the home health agency’s commitment to compliance and address specific areas of potential fraud;
- The designation of a compliance officer and other appropriate bodies, charged with the responsibility for operating and monitoring the compliance program;
- The development and implementation of regular, effective education and training programs for all affected employees;
- The creation and maintenance of a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation;
- The development of a system to respond to allegations of improper/ illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or Federal health care program requirements;
- The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas; and
- The investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals.
As a home health agency do you know whether your compliance program is effective? If you have questions regarding the effectiveness of your compliance program, please contact Clifford E. Barnes or Marshall E. Jackson, Jr.
Epstein Becker Green and EBG Advisors, as part of the Thought Leaders in Population Health Speaker Series, will host a complimentary webinar titled Moving to an Integrated Population Health Management Model. This session will highlight several approaches to help manage populations to promote better clinical outcomes, more cost savings and enhanced patient satisfaction.
The webinar, scheduled for October 30, 2014 at 12:00 p.m. ET, will be led by Sarika Aggarwal, MD, Senior Vice President and Chief Medical Officer of Fallon Community Health Plan, and Julie O’Brien, RN, BSN, MS, Senior Vice President and Chief Operating Officer of Alicare Medical Management, and moderated by Mark Lutes, Chair, Epstein Becker Green.
For more information, please click here. To register, please click here.
Epstein Becker Green today announced that Lynn Shapiro Snyder and Tanya Cramer have written a newly released topical Portfolio for Bloomberg BNA on provider risk sharing arrangements entitled, “Accountable Care Organizations and Other Provider Risk Sharing Arrangements, 2nd edition.” The Portfolio discusses the federal and state regulatory schemes for accountable care organizations (ACOs), integrated delivery systems, and other provider organizations that assume some or all of the financial risk for providing covered health care benefits to patients. For more information, click here.
By Stuart Gerson
The September 30, 2014 decision of a United States District Judge for Eastern District of Oklahoma in the case of State v. Burwell adds an interesting wrinkle to the debate over whether the provision in the Affordable Care Act that authorizes federal subsidies (tax credits) applies to individuals who are covered by a qualified health plan that is enrolled through an Exchange established by the Federal government, not a State. An IRS Rule (26 C.F.R.§ 1.36B-1(k)) allows this, while the ACA itself bases eligibility on participation in a plan that was “enrolled in through an Exchange established by the State . . . .” 26 U.S.C. §36B(b)(2)(A). These provisions also affect ACA subsidies that relate to employers. Holding to the literal language of Affordable Care Act itself, the Oklahoma District Court held that the IRS rule was unlawful.
As we’ve previously noted, there had been a split in the United States Courts of Appeals created on the same day when a panel of the DC Circuit took the same literalist approach in Halbig v. Burwell as did the District of Oklahoma, but the 4th Circuit ruled in King v. Burwell that “Exchange” meant any Exchange and held that the ACA subsidies were available to anyone who was a subscriber to a health plan in a state that had not established its own Exchange but where the Federal government had. This split, however, was quickly erased when the DC Circuit, as a whole, vacated the panel’s decision and voted to rehear the case en banc, which it has yet to do. Without any split to rely upon, a factor that increases the probability of Supreme Court review, the 4th Circuit plaintiffs nevertheless have petitioned for cert., claiming that the case should be taken because it presents an important question of federal law that must be resolved at some point. The Supreme Court has not yet acted on that petition.
The District Court in Oklahoma stayed its order and the Obama administration will file an expedited appeal. If the 10th Circuit affirms the case quickly, that would create a new Circuit split and very well could serve as a catalyst for Supreme Court review. We’ll keep you posted as this is a matter that affects both employers and employees in the States that have not established Exchanges.
Our colleagues Adam Solander and Ali Lakhani provide an update on the HIPPA Conference last week in Washington, DC.
On September 23 and 24, 2014, the National Institute of Standards and Technology (“NIST”) and the Department of Health and Human Services Office of Civil Rights (“HHS OCR”) hosted their annual HIPAA conference “Safeguarding Health Information: Building Assurance through HIPAA security.”
OCR officials and key industry leaders engaged in dialogue regarding developments and trends in data breach incidents with respect to health information as well as stakeholder responses and best practices to mitigate risk and respond to potential incidents.
For the full post, please visit the TechHealth Perspectives blog.
Epstein Becker Green colleagues Robert S. Groban, Jr. and Matthew S. Groban provide an update to the health care industry in the Immigration Alert: September 2014, including an update on the Sixth Circuit Expanding the Liability of Health Care Employers for Sponsorship Costs.
Based on the Kutty decision, health care employers can expect more aggressive enforcement activity in connection with their employment of foreign nationals (“FNs”) generally and foreign medical professionals sponsored for H-1B classification and J-1 waivers of the two-year foreign residence requirement that many J-1 residents face. For the full client alert, click here.
Our Epstein Becker Green colleagues have released a new Take 5 newsletter: “Five ACA Issues that Employers Should Be Following” by David W. Garland, Adam C. Solander, and Brandon C. Ge. Below is an excerpt:
Employers have about three months to finalize their employer mandate compliance plans under the Affordable Care Act (“ACA”). While most employers are in the final stages of planning, this month’s Take 5 will address five ACA issues that employers should be aware of as they move forward:
- ACA-related litigation
- Employer mandate reporting
- Section 510 liability
- Alternatives to traditional plan offerings
- The looming Cadillac tax
Read the full newsletter here.
Epstein Becker Green is pleased to announce that Paul A. Gomez has joined as a Member of the Firm in the Health Care and Life Sciences and Corporate Service practices, in the Los Angeles office. Paul’s arrival brings added strength to Epstein Becker Green’s health care practice, particularly its transactional work, on the West Coast. His experience representing a wide array of providers complements the services that the firm provides in that area, from structuring mergers and acquisitions, joint ventures and strategic affiliations, to counseling on compliance with fraud and abuse laws, and advising on provider licensing and reimbursement matters. For further information please click here.
Epstein Becker Green and EBG Advisors, as part of the Thought Leaders in Population Health Speaker Series, will host a complimentary webinar on September 30, 2014 on emerging trends in value-based purchasing in health care. The next session will feature a former key official from the U.S. Department of Health and Human Services (HHS), Gary Cohen, JD, who played a central role in the implementation of the Affordable Care Act over the past several years and is moderated by Lynn Shapiro Snyder, Senior Member, Epstein Becker Green. The session, The Impact of the Affordable Care Act on Population Health Management, will assess how much progress the federal and state governments have made expanding health care coverage and bending the cost curve. Specific insurance reforms to the individual and small group markets will be examined along with emerging trends such as the role of accountable care organizations (ACOs), patient accessibility issues, and the drive towards integrated population health solutions.
For more information, please visit: http://www.ebgadvisors.com/cciio-director-gary-cohen-address-key-health-care-reforms-impact-population-health-management/.
By Stuart Gerson
As we noted in our various blogs and communications on the subject (HEAL Advisory and HEAL Blog), the United States Court of Appeals for the District of Columbia Circuit’s action today, to rehear in December the Halbig case (Halbig v. Burwell, D.C. Cir., No. 14-508 ), challenging Obamacare subsidies in the federal health exchange, is not unexpected given the current makeup of the Court. This development now makes it more likely that the Supreme Court will not take action on the King cert petition (King v. Burwell, U.S. 4th Circuit , No. 14-1158) until after the DC Circuit decides the Halbig case, which will be argued on December 17th. The DC Circuit’s likely action (either vacating the panel opinion or overturning it) also will erase the split in the circuits and thus make it less likely that there will be four SCOTUS Justices who will vote to take the case.