Charden T. Virgil, MPH
Aegis Compliance & Ethics Center, LLP
Houston Home Health Agency Owner Sentenced to 480 Months in Prison
According to an article released by the US Department of Justice (“DOJ”), US District Judge Sim Lake sentenced the operator and owner of five Houston, Texas area home health agencies to 40 years in prison for colluding to defraud Medicare and state Medicaid service programs of over $17 million. The charges also include money laundering, which elevates this case as the biggest provider attendant services (“PAS”) fraudulent incident charged in Texas history. Some of the accused perpetrators are physicians as well as Medicare and Medicaid patients.
In July 2017, the Department of Health and Human Services (“HHS”) Office of the Inspector General (“OIG”) struck down the largest Medicare fraud operation in US history. Over 400 defendants, including 115 medical professionals, were charged for their alleged participation in fraudulent schemes amounting to a total loss of $1.3 billion. As a leader in Medicare fraud takedowns, the Medicare Fraud Strike Force has accused more than 3,500 individuals of deceitfully billing Medicare for a whopping $12.5 billion since its establishment in 2007.
The HHS and DOJ agreed to vigorously eliminate Medicare fraud and abuse. Medicare fraud encompasses both the purposeful submission of false healthcare claims and the receipt of payments for items or services that Medicare and Medicaid reimburse for. Medicare abuse comprises of practices that result in unnecessary costs to the Medicare Program, such as unbundling codes. Although meticulous and complex fraud and abuse schemes receive lots of attention, Medicare fraud and abuse schemes can be unintentional.
How do we Mitigate Fraud and Abuse in the Medicare Program?
Internal Auditing and Monitoring
Providers and healthcare institutions should internally audit and monitor their systems. Healthcare organizations need an internal checks and balances system to ensure standards are followed. An effective compliance program follows the money, and compliance officers, for instance, audit for kickbacks and confirm that any Medicare or Medicaid funds received are used appropriately.
Due to the threshold approach to reviewing claims, many payers inadvertently omit fraudulent schemes, as numerous fraud and abuse incidents are not big dollar schemes. Thus, only roughly 3-5% of late-stage fraud is truly discovered.
Training and Education
Training and education programs serve as vital components to combating the overall issue. These trainings should highlight the importance of accurate documentation and coding. Training providers on Medicare rules and policies will regularly alleviate some of the fraud and abuse. Additionally, physicians should be educated on fraud schemes such as the one mentioned above so that they will be aware of the latest fraudulent tactics.
Furthermore, non-licensed medical professionals should know their roles not only in reporting fraud and/or abuse but also ways to ensure they are not complicit in such acts. Despite the effectiveness of internal auditing and training, bringing in external personnel with expertise in compliance offers an invaluable and unbiased perspective.