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Posts from the ‘Medicare Fraud and Abuse’ Category

Company 1


Take heed

Suzanne May, age 61, served as the administrator of a hospice referred to by the Feds as Company 1 for more than a decade She was a both a registered nurse and a certified hospice administrator. She signed a plea deal admitting to fraud on December 3, 2019 and now faces five years in prison followed by three years supervised release, a $250,000.00 fine and to top it off, a $100.00 special assessment. Hopefully, her lawyer can negotiate a deal where the special assessment is knocked off of the overall penalties.

Altering Legal Documents

To keep it short and simple unlike the official documents, Ms. May has admitted to:

  1. Using white-out on a Certificate of Terminal Illness. If you can’t figure out why that might be a problem, it’s best that you resign now.
  2. Adding dates to Notices of Election after the clinical records were requested from Medicare. I do not know how Federal Investigators knew when the dates were added.
  3. Ms. May relieved some patients of the burden of initialing forms by adding their dated initials to forms. The Feds are alleging that it is not possible to sign and date documents after death.

In an impressive display of organizational skills, Company 1 employees, led by Ms. May, kept a log of all changes made to the documents after the request for records was received.

This audit, performed in 2017, followed a 2015 audit in which close to $400,000 was returned to Medicare. As a certified hospice administrator Ms. May knew what was required of the hospice in order to be paid. And, to her credit, she made sure every detail was complete but only after her clinical records were requested by Medicare. Timing is everything.

Look Again

This post teaches you how to go to jail. Free meals, a warm place to sleep and a break from your needy relatives may be your ticket to jolly holidays. Surely the worst prison food is better than fruit cake and squash casserole.

In no way am I condoning the actions of Ms. May. I also recognize that the criteria for payment is sometimes preposterous. Claims for reasonable and necessary care provided to eligible beneficiaries are denied payment every day but that is a subject for another post.

In this case no patients were harmed as a result of Ms. May’s actions. Nobody dies from a date added to a document after they die. If jail is your ideal vacation, this seems to be the way to go if you don’t want any patients to be hurt along the way.

If you wish to remain home with your loved ones, I assure you that no matter how tempting it is to add a date to a form because the patient didn’t, and you know the correct date and personally witnessed the patient sign the form, it isn’t worth it. When a physician doesn’t date his or her signature and you know when the orders were signed, adding the date seems more like a courtesy than a felony but you would be wrong in making that assumption.

If this sort of behavior was evident on a state survey and a plan of correction to the state was required, it would probably include an educational piece like, ‘The DON will hold an inservice to teach the nurses things that they already know but didn’t do.’

If you are finding these problems during clinical record and billing review despite teaching the nurses repeatedly it’s time to try something new.

Cut your employees some slack. Home health and hospice nurses who provide excellent care to your patients are worth a little extra time. Review their paperwork with them as it arrives at the agency – which usually occurs before the time (and possibly the patient) has passed to get an ethically dated signature. Help them develop habits.

On the other hand, if a nurse blatantly commits fraud, investigate first and then terminate them. You are also obligated to report them to Medicare and their State Board. A good orientation will ensure they know the rules. Protect your nurses and the agency by providing a complete orientation including compliance. 

Do not bill (or alternatively, pay back the money) if you have found out that a nurse was taking shortcuts. It is painful to take the right steps but not as painful as the quarter million fine Ms. May will pay (plus the assessment fee).

If you are a visiting nurse, you know the rules. You know what to do and mostly you get it right but it only takes a couple of bad care plans or notices of election to cost an agency tens of thousands of dollars.

More concerning to me is the probability that some nurses are encouraged to ‘do what it takes’ to get billing out the door. Without using the words, ‘go commit fraud’, some employers leave employees feeling like their jobs are on the line if they hold up billing. If you feel that the only way to keep your job is to fill in the blanks omitted by a patient or a physician, I guarantee that unemployment is a better option.

Everything else aside, ask how Medicare knew the documents were altered by Ms. May and friends after the patient died. The Feds are not psychic. They did not have a seance summoning J. Edgar Hoover who revealed the exact time that dates were placed on documents. They obviously knew something that was solid enough for them to request 100 charts.

I’m willing to bet that Company 1 is not the real name of the hospice and that this story has just begun. Until we find out more, do yourself and your patients a favor and do things the right way. If you are preoccupied with compiling charts for an audit, care to your patients will be compromised. I’ve seen it too many times.

As always, your comments are welcome or you can email your thoughts.

Turning Point


My understanding of the events that shook my world last night is that they began before Hurricanes Katrina and Rita.   Although I am not certain of this, it seems that an investigation into Abide Home Health began prior to the storms but the evidence was washed out to sea.   I can’t say if that’s true or not but it adds a level of interest to the story knowing that the agency had a new chance to do things right and chose not to do so.

The case involved over 20 defendants, illicit sex, a dash of racism, the mother of a prominent football player (The Honey Badger), a large oil company and two Zulu Queens.  For those of you not from the South, Zulu is a Mardi Gras parade and they were Carnival Royalty. This is a big deal in New Orleans social circles.

To be sure, this case was juicy.

Imagine for a minute that you are one Lisa Crinel involved in a romantic relationship with your lawyer when a search warrant is executed relating to a fraud investigation involving your business.  Imagine if it was signed by a federal judge who was married to your lawyer.  Now imagine that you are the lawyer when Lisa Crinel files a lawsuit alleging that the lawyer ‘“never informed Ms. Crinel that it was a conflict of interest for him to represent her and her company while carrying on an extramarital affair with her….”   Yes, indeed.  How else could she have known?  I’m betting the judge was unaware of the affair when she signed the search warrant because it didn’t include a cavity search.

For some people, Medicare fraud isn’t enough.  The original press release from the US attorney’s office in Eastern Louisiana alleges that Lisa Crinel created false documentation to support claims for two employees and her daughter so that they could collect money from the funds provided by BP to compensate real victims of the Deepwater Horizon oil spill.  Classy.

Moving right along, Ms. Crinel had already lost 1M to the feds who seized her property even before she was indicted.  This was interpreted by Lisa Crinel as being racially motivated because they did not seize the property of another Medicare defendant accused of the same crime.    I believe there is a possibility that something, other than race motivated that decision.  Could there have been a previous overpayment?  How strong were her ties to the community?  I have to admit, a beach in a country without extradition might have appealed to me if I were in that position.   I sincerely hope that federal investigators did not simply seize her property and bank accounts with no good reason prior to the indictment because in spite of mountains of evidence, Ms. Crinel was innocent until proven guilty.

The Turning Point

In October of 2015, Lisa Crinel woke up with a newly calibrated moral compass.  In exchange for a lighter sentence of no more than 8 years and an agreement from the Assistant US Attorney that all felony charges be dropped against her daughter who served as CEO, she pleaded guilty.  She explained her decision, ‘because I am in fact guilty, and because I did not want to put the government through the unnecessary expense and trouble of proving this in court. I also pled guilty because I understand that accepting responsibility for the wrongs that I have done is the first step toward correcting them.”

Of course, she also agreed to provide the prosecutors with any truthful cooperation in any way she could.  According to Ms. Crinel, this was a genuine personal turning point for her, not just a legal one.  Yes.  That’s what she said.

The Sad Part

Last night, four doctors were convicted of multiple counts of Medicare fraud.  The longest possible sentence I saw was 170 years although the sentencing date has not been set. yet.  Are they guilty?  I think they are.  I still don’t know all of the details but the Feds don’t lose.   They knew this case was their’s for the winning when they took it on.  They turn away far more cases than they accept and the do not indict until they are certain they have a case.

Of the four, I know one mainly through his office staff.  I know that he was with his grandson who was receiving chemo when his office was raided.  I do not believe this was an accident because I’ve heard too many other stories about the feds arriving when the targets of their investigation were least available.  I have followed behind this doctor and another and read their clinic and hospital documentation for years.  The truth is that they are razor sharp physicians who are responsive to their patients and the nurses who call them for orders.

They are basically good men.

So, what happened? One doc received $3,500.00 a month from the agency – $1,000.00 more than would be allowed by law assuming he worked for the paycheck.  None of the doctors were poor and they all made more money than most people reading this blog.

My anger towards the owner of the agency is what I hang on to while these questions still linger.  Lisa Crinel owned Abide Home Health.  Her daughter was the CEO.  They wrote and signed checks that went to physicians.  They paid a physician’s wife an inflated salary so that her husband would refer patients.

Did the docs approach her asking for a Medical Director position?  I bet they were approached by Lisa Crinel.  And what they saw was a successful business woman in New Orleans – an economic nightmare since the storms in 2006.  They saw someone who had overcome the odds and lived well.  They signed orders because she or her agents asked.  Did they trust that the orders were legitimate?

Did they get a little greedy rationalizing that the dollar amount of money may be technically fraud but they deserved it?

These physicians could not have realized they were risking what may amount to life sentences for the relatively small amount of money they received.  But that doesn’t matter.  The standard isn’t what you know but rather what a reasonable person in the same position has the responsibility to know.

Lisa Crinel had the jewels and cash paid for by the proceeds of the fraud.  She was a New Orleans socialite; queen of Zulu.  She was a leader of the community and she lead dozens of her followers to the jailhouse.  While the physicians earned most of their money providing care to patients, she stole all her money by committing fraud.  And when she ran out of lawyers available for affairs and the BP scheme fell flat and nobody would believe that her African American heritage was the reason the feds were picking on her, she turned on the very people she recruited to participate in her fraud scheme.  I’m not sure I have any respect for her.

And New Orleans has lost two great physicians and two more that may or may not be great.  I’m not disagreeing with the verdict but I still find it sad.   The jury found them guilty and I trust the jury.  But they are guilty of fraud; not of being scumbags who systematically scheme to steal as much as they can from the government.   Sometimes good people break the law.

PEPPER Reports


What if I could tell you how likely you are to find your agency under intense scrutiny by Medicare?  Would you want to know?  What if I could tell you what Medicare expects you to do to address any risk areas?  Would you do it?

Chances are the answer is a resounding, ‘No!’

You can have all this information within 15 minutes.  All you need is your provider number and a patient ID number for a claim that has been paid prior to July 17, 2016.  Both of these numbers are available on any 485.

Using these two numbers, any Medicare certified home health care agency can access the PEPPER portal.  There you will find your agency specific reports that show where an agency falls compared to other agencies in areas that Medicare has identified as those being closely associated with Medicare fraud and abuse.  Of all certified home health agencies, only 20 percent nationwide have bothered to look at their data.

One nurse asked me if maybe it was better not to download reports.  Her rationale was that if Medicare would come down harder if they believed the agency was aware of any high risk areas as opposed to being unaware.  To be clear, Medicare is not going to cut you a break if you didn’t know that your agency was meeting the threshold for any of the target groups reported.

Here’s what the PEPPER reports show:

Average Case Mix

Agencies with an average rate of 1.6 or higher may find themselves looked at for possible up-coding.

Average Number of Episodes    

Nationwide, agencies in the 80th percentile provide an average of 2.78 episodes.  Medicare believes there is a high chance of improper payments if you meet or exceed an average of 2.78 episodes per patient.

5 or 6 Visits                                       

In order to get paid the full amount for an episode, an agency must provide at least five visits.  Any nursing care over and above five visits adds to the cost of the episode but not to the payment.  If your agency has more than 7.2 percent of their episodes with five or six visits, Medicare believes there is a chance that you are maximizing income without regard to patient care.

Non-Lupa Payments                      

Medicare expects that agencies will have LUPA payments.  When the number of LUPA payments is very low, Medicare suspects that an agency is avoiding LUPA costs by providing unnecessary visits to qualify for full payment.

High Therapy                                    

Although some patients require 20 or more therapy visits per episode, the assumption is that agencies in which 2.9 percent or more of patients required 20 or more visits may be adding unnecessary visits to capitalize on the enhanced payment associated with high therapy.

Outliers                                              

The target for outliers is 7.6 of total payment.  Note that this is less than 7.6 of total episodes.   Anything over 10 percent will be adjusted quarterly.

These indicators of possible improper payments are only data.  It is possible to hit the target in one more areas without doing anything improper.  However, a prudent agency will be well aware of where they fall and document accordingly.  Should questions arise, the agency should be able to provide an explanation as to the aberrancy.  If you cannot arrive at a suitable answer, take a long and hard look at your charts.

The PEPPER reports that have been shared with us do not approach any level of concern.  (Fraudulent agencies often eschew our services which focus on compliance.)  My guess is that PEPPER Reports are effective at identifying improper payments.  Agencies that routinely provide three episodes per patient and all the episodes have exactly 6 visits may not be assessing the patient and meeting their individual needs.   If you are employed by an agency that has hit multiple targets and seems disinterested in addressing them, you may want to reconsider your current employment status.

If you decide to download your PEPPER reports, please let us know.  If you feel like sharing them, we’d love to see them and promise to keep them confidential.

End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

Read more

My New Hero


 

Like most superheroes, it is best to worship him from afar.  In fact, I don’t know his name and do not want to because I like a world full of possibilities.  My new hero is a physician in Florida and because he remains anonymous, every doctor in Florida could be him.  Florida is even sunnier and warmer with all those potential superheroes in white coats.

There are some heroic physicians who save lives or invent new procedures.  For the longest time, I was leery of the Whipple procedure because I was unaware that it was named after Allen Whipple.  I thought the term ‘Whipple’ referred to a technique and I didn’t want to know anything more.

Other heroic physicians travel to countries far and wide taking care of patients that have no one else.  These docs and other healthcare providers also have my undying admiration.

My new hero is a different breed, though.  I know of him by a client’s report that he documented homebound status on a Face-to-Face encounter with the following:

He is.  This is a stupid question.

Many of you may think that compared to Christian Barnard or Allen Whipple, this isn’t really such a big deal.  You could be right but I don’t think so.

In order for Drs Whipple and Barnard and the like to be of value to society and their chosen field of medicine, three things must happen.   The first is that the patient must live long enough to have the procedure done.  The surgery must be performed on a candidate well enough to undergo the procedure.   The patient must receive nothing short of excellent care after hospitalization.   Sadly this involves money.   (Average operating room time alone, without physician charges costs $147.00 per minute.)

Meanwhile, home health agencies are being denied daily because the physician does not document how the patients condition confines them to the home.  Claims are denied even when patients are recently discharged from the hospital with a serious illness or surgery to replace something like a hip or heart or whatever.

When home health care agencies don’t get paid, they are faced with choices that eventually result in providing care that is substandard or closing their doors altogether.  That means a poor outcome for the replacement parts.

We have all tried, in our own way, to gently hint to Medicare that the F2F encounter document is stupid.  NACH has even filed a law suit full of big words spanning numerous pages.  Medicare responded that they may relax the requirement in the distant future but no further word has been forthcoming.  I suspect they just wanted to minimize the importance of NAHC’s lawsuit.  I could be wrong, though.  Never let it be said that I am always right.

My hero, the unknown physician, has described in five words, why Medicare is getting so little compliance on the F2F matter.  Please note that the physician wrote two complete sentences with both verbs and nouns and I hope he gets partial credit for writing a grammatically correct narrative that doesn’t simply restate what is written in the manuals about homebound status.

Like most docs our superhero probably saves a few lives here and there and makes other people feel much better about being alive when he isn’t answering stupid questions on a stupid form verifying that he saw a patient he just discharged from the hospital.

Luckily for my diligent client, the claim had not been dropped for the patient yet.   I hope they make a photo copy of the original document before they go waste another hour of their time and the doctor’s time by once again explaining what an expensive comment that was and asking for a do-over.  If this chart is ever summoned by the payor sources, I  think I would include the original and the Do-Over.  You know, just a subtle little message – because I am all about being subtle.

Will everyone please bow their heads and give my hero  a moment of silence in honor of his insight into our daily struggles.  It is the least we can do for a physician who has contributed so much to so many.  Hopefully there are more waiting to come out of hiding.

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