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Posts tagged ‘Medicare Fraud and Abuse’
By now, everyone has heard of the very busy Dr. Jacques Roy who had more home health care patients than anyone in the entire united states and is accused of causing greater than 345M in false claims to be billed to Medicare.
Have you read the actual indictment, though? It names at least two RN’s as well. That really doesn’t bother me because I don’t count nurses who pay homeless people money as colleagues. I do so hope they lose their licenses.
What was tucked in at the bottom of the most recent article that came across my desk is that 78 home health care providers have apparently had their payments suspended pending the results of a full investigation.
This sounds extreme and it is because of the number of agencies that have payment suspended. However, these are not the first agencies who have had payment suspended because of ties to known or suspected physicians.
One client was assessed an overpayment of greater than 3M. This is small time compared to the 345M that makes headlines. Nevertheless, payment was suspended. Another agency with the same medical director likewise had their payment suspended. The second agency was not in a position to hire me due to the profoundly impaired cash flow.
Check your docs, folks. After these agencies had funds suspended I began researching the docs for all ZPIC clients. It is amazing what was found. The problem is that the state board of medicine doesn’t actually report on issues while they are still under investigation. In fact, the medical director referenced above was in jail for 8 months before the OIG added her to the exclusion list. The state board of medicine still lists the license as active and having no disciplinary history. (Jail doesn’t count, I suppose.)
I got the good stuff the way I get all the good stuff. I googled the docs. The press love photos of physicians being escorted out of buildings by men in uniforms. If there are handcuffs involved, it makes the first page.
If a physician has a restricted license, be sure that you are fully aware of the restrictions. Some physicians in recovery are not allowed to prescribe scheduled meds. Often a nurse will write all meds a patient is taking including scheduled meds from another physician. When the restricted doc signs the 485, he has just violated his license. I had never come up against that before and frankly, I do not know how these will fare during review. I am not hopeful, however.
For what it is worth, the client who was assessed the greater than 3M overpayment arranged to borrow the money from the bank so that Medicare could be paid back and the agency would be able to function until the appeals level of the audit. Medicare said, ‘thanks but we are not restoring your payments until after the entire investigation is complete.
In other words, a year or longer. That means that there are effectively 78 fewer agencies in Dallas this week.
On the bright side, you may get a really good deal on a licensed only agency but you will not be able to bill until you establish a new provider agreement with Medicare. Remember, if you purchase a provider and assume their provider agreement, you have assumed their debt to Medicare. You would think that would be obvious but it’s worth stating again.
So, check your docs. If you find out any good stuff about docs in my area (Louisiana, TX, Fl, AL), send me a discreet email at email@example.com so I can ensure my clients are not unwittingly involved with someone who will get their cash suspended.
Today, in Baton Rouge, someone was sentenced to prison for recruiting patients. While goofing off on the internet, I came across this story by Investigative Reporter Terri Langston published in the Houston Chronicle. Click on the image to read the full text which involves over 100M dollars in fraud and again, patient recruitment.
Now, color me clueless, but I really do not understand the difference between recruitment and marketing in the context that normal people use the terms in daily life. If you look up ‘patient recruitment’ you find tons of articles on how to recruit patients………. for clinical trials.
The dictionary defines recruit as, ‘to seek to enroll’ as students. This does not seem worthy of jail time either. Solicitation doesn’t seem all that horrible either. When I write a post and tell you to please call if you need help, wouldn’t that be soliciting your business?
So who better to consult than a health care lawyer.
Christopher Johnston has the distinction of knowing more people who have been or will go to jail than anyone else I know. (It is relevant that I have a very good friend on the SWAT team.) This is because he is one of the best lawyers for keeping healthcare providers out of jail or reducing their sentences. He also has to work with what he gets from clients and sometimes, well…… a couple of years is better than twenty. Chris’s success rate for clients who call him before they are in trouble is stellar.
He has a list of commandments to follow should you want to stay clear of any accusations of inappropriate marketing. Read them and share with your marketers. Chris is not a cheap lawyer and I am giving away his advice for free. Take it and run with it. Or don’t. Just remember that in this period of intense scrutiny, a reduction in your sentence may be the best anyone can do for you after you get caught.
- Do not bribe, harass, coerce, or intimidate any patient into selecting or changing agencies. (Julianne’s note: In reading Animal Husbandry Weekly, I gather it is okay to sell cattle per head. In reading the HEAT Task Force News page, I gather it is NOT okay to sell or buy referrals per head.)
- Do not allow any of your employees to bribe, harass, coerce or intimidate any patient into selecting or changing and agency. (Julianne’s note: What do you think a marketer will tell the investigators when they are caught? Do you think they will say their employer knew nothing about it or will they throw you under the bus?)
- Do not falsely advertise about any services, awards or credentials or anything that may mislead the public. (Julianne’s note: A nurse without a license is not a nurse for the purposes of home health. If you advertise nursing care, please send licensed nurses only.)
- You may certainly respond to inquiries about home health but DO NOT initiate the conversation. (Julianne’s admission of guilt: I might have to go to jail if I heard of someone who really needed home health but I would NOT – and do not – recommend specific agencies.)
- Do recommend that the patient contact his or her physician but do not recommend a physician to the patient. Under NO circumstances should you ever bring a patient to the physician or the physician to the patient’s home. (Julianne’s note: If you do not believe this happens, talk to your folks at MD offices. The waiting rooms are filled with aides bringing patients to MD offices.)
- Do not go into people’s homes or call them on the phone to tell them about the availability of home health. (Julianne’s note: We did not need a lawyer to tell us this, I hope and yet, I know of instances where it has happened.)
- Do not conduct marketing inservices in people’s homes. Stick to the physician’s office.
- Never, ever offer anything of value to anyone in an effort to select your agency or refer to your agency. (Julianne’s note: See the way Chris used both of the words, ‘never’ and ‘ever’ in his advice. I know from experience this means he is deadly serious about giving people cool stuff in return for being your patient or referring to your agency.)
Specifically excluded from these guidelines is community education. If you think about it, when providing support groups and speakers for community functions, you are generally not interacting with people who would meet the home health requirements for homebound status so there are no ‘patients’ involved.
The truth of the matter is that every time an agency gets closed down or someone goes to jail, it reduces my pool of potential clients. And remember, it is all about me.
And it is about you. My experience is that nurses who violate these guidelines typically are unaware that they exist. I am not completely innocent here. I have paid for drugs on occasion and also food. (Attention: if you are a federal agent or work for a contractor who has the authority to arrest fraudulent nurses, I haven’t been in the field since the 90’s. Surely there is a statute of limitations. If not, can I write my blog from prison?)
We can’t do this anymore. We absolutely must put safeguards in place to protect us from having to tell a client we are so sorry they have no meds or food but can’t anything about it. Because nurses are not wired to do that and we will end up in trouble if we don’t act preemptively. This means hooking up with your local food banks and indigent pharmacies and getting to know how they work before you need them. And when you have a few dollars to give away, donate them to the pharmacy or food bank.
And if you don’t have a formal compliance plan, contact me. If you have unwittingly participated in any of the above, contact Chris. We can help you. There I go again – soliciting business. It actually works. Sorry you can’t participate.
While searching the internet in an unrelated issue, I stumbled upon the OIG page related to fraud and abuse in health care where false and fraudulent claims are listed. Below is what was reported regarding an organization called Shopko Stores in Utah. Notice that the OIG imposed a monetary penalty greater than a half a million dollars for employing someone that the organization ‘knew or should have known’ was excluded from the Medicare program. From the Office of Inspector General’s Fraud and Fraudulent Claim web page which can be found here.
After it self-disclosed conduct to the OIG, ShopKo Stores, Inc. (ShopKo), Utah, agreed to pay $669,824.74 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that ShopKo employed an individual that ShopKo knew or should have known was excluded from participation in Federal health care programs.
Since Medicare Providers are held to the standard of ‘what should be known’ in addition to what they actually know, reasonable diligence is expected. The surest way to protect your agency is to develop a comprehensive corporate compliance program. At the very least, agencies should check all employees and referral sources against the OIG exclusion database which can be found by accessing this link.
Haydel Consulting Services cheerfully assists agencies in developing their own corporate compliance plan. We are certainly less expensive than OIG imposed civil monetary penalties. Please feel free to contact us at 225-253-4876 or firstname.lastname@example.org.