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OIG Releases Fraud, Waste, and Abuse Alert Concerning HHAs and Home-Visiting Physicians

Recently, the Office of Inspector General (OIG) published an alert spotlighting recent fraud, waste, and abuse in the home healthcare setting.  Specifically, the alert focused on various types of violations and improper conduct alleged against home health agencies (HHAs), individual physicians, and heads of home-visiting physician groups.

The OIG alleges that HHAs have been entering into improper referral and/or compensation arrangements with physicians in violation of the federal Anti-Kickback Statute (AKS).  These AKS violations involve HHAs paying money to physicians in return for referrals of the physicians’ Medicare patients to the HHAs for home health services. The converse also occurs, with physicians soliciting referrals to the HHAs in return for monetary compensation.  Not all compensation arrangements between HHAs and physicians are prohibited, as is noted by the OIG, but an arrangement may implicate the AKS if even a single purpose of the arrangement is to remunerate physicians for referring (including past and future referrals) Medicare or Medicaid patients to the HHA.  Additionally, even in the absence of patient referrals, any compensation arrangement between HHAs and physicians is required to be commercially reasonable and based on the fair market value of the services rendered.

In addition to the alleged AKS violations, other federal laws were said to have been violated by HHAs and physicians pursuant to these compensation schemes.  Examples outlined in the OIG alert include: HHAs billing for nursing home services rendered to Medicare patients who were not actually confined to the home; physicians falsely certifying patients as homebound; physicians billing for up-coded levels of home visit evaluation and management (E/M) services; and physicians billing for care plan oversight (CPO) services that were not actually provided.

With this alert being released shortly after the Centers for Medicare & Medicaid Services’ (CMS’) Pre-Claim Review Demonstration for home health services was announced, it is evident that HHAs remain under strict government scrutiny.  And given this current environment for providers in the home care setting, it is vital for providers to ensure they are in full compliance with federal health care laws.

For over 30 years, Wachler & Associates has represented HHAs, physicians, and various other health care provider and supplier types nationwide in a wide range of health law matters, including compliance with the Anti-kickback Statute and Medicare billing and documentation requirements.  If you or your entity has any questions regarding compliance with federal or state health care laws, please contact an experienced healthcare attorney at (248) 544-0888, or via email at wapc@wachler.com. You may also subscribe to our health law blog by adding your email at the top right of this page.