<img alt="" src="http://www.qpwoei2.com/100802.png" style="display:none;">

Ankota: Ushering in the Next Generation of Homecare Blog

Inappropriate Home Health Referrals and Billing Lead to Convictions

Posted by Ken Accardi on Mar 27, 2014 11:53:00 AM

At Ankota, we believe that home care should play a vital and increasing role in health care reform.  Keeping elderly and fragile patients out of the hospital andHome Health Software in their homes can greatly reduce health care costs and improve outcomes.  But home health is under constant pressure because of decreasing reimbursement and somewhat of a negative perception by lawmakers.  The below article from attorney Elizabeth Hogue explains why.  Hopefully the few bad apples will continue to be proscecuted to clear the good name of the industry.

Inappropriate Actions by Medical Director Result in Convictions for Fraud

by Elizabeth Hogue

A Medicare-certified home health agency had a Medical Director.  Among other activities, the Medical Director signed certifications and recertifications for hundreds of patients of the Agency.  Many of these patients did not qualify for services under the Medicare home health benefit because they:

  • Were not confined to their homes.
  • Did not need skilled nursing services, physical therapyHome Care Fraud Jail or speech therapy on an intermittent basis, or occupational therapy on a continuing basis; and
  • Were not under the care of physicians who established plans of care for home health services.

Prior to initial certification of eligibility, the Medical Director documented that he or other qualified health care providers had face-to-face encounters with patients that showed that the patients were homebound and in need of home health services. 

Despite these requirements, the Medical Director certified hundreds of Medicare beneficiaries for home health services provided by the Agency without conducting face-to-face encounters with these patients.  Most of the patients were not referred to the Agency by their primary care physicians or other physicians who examined them.  Instead, the Medical Director often signed certifications after spending minimal amounts of time reviewing patient assessment forms that were 

Elizabeth Hogue home health attorney

prepared by Agency nurses, and/or participating in brief discussions about patients with Agency nurses or the Agency's Clinical Director. 

If the Medical Director had reviewed the patients' records more closely, he would have discovered information that showed that many of the patients were not homebound because, for example, they worked, took vacations, and spent substantial amounts of time outside of their homes.  Patients' records also showed that many patients did not request home health services and/or were not provided with skilled nursing services.

In addition, the Medical Director billed Medicare Part B for both the certifications and subsequent recertifications that he provided.

The Medicare Program paid the Agency over $1,000,000 for the services certified by the Medical Director, even though patients did not have face-to-face encounters that met applicable requirements.  In addition, the Medical Director received approximately $30,000 for certifications and recertifications. 

Based upon the above, the Medical Director, the owner of the Agency and the Clinical Director of the Agency were charged with conspiracy to commit health care fraud and 11 counts of health care fraud, among other charges. According to th

Health Care Reform

e indictment, the owner and the Clinical Director of the Agency conspired to fraudulently induce the Medicare Program to pay for home health services that most Medicare patients did not need or want. They trained field nurses to recruit Medicare beneficiaries who lived in residential facilities by asking if they were insured by Medicare and, if so, if they would like a nurse to visit them in their homes. 

The indictment also alleges that the owner and Clinical Director trained nurses to manipulate patients' initial OASIS assessments to make it appear that patients qualified for home health services even though this was usually not the case.  The Medical Director then signed certifications and plans of care that certified that patients were homebound and in need of skilled services when they were often neither homebound, nor in need of such services. 

There are many lessons for agencies in this case, including that Medical Directors cannot sign certifications and plans of care unless they are the patients' primary physician and responsible for the continuing care of patients.  In addition, this case illustrates that members of the management teams of agencies, including Clinical Directors and others, will be held responsible for fraudulent conduct that occurs on  their "watch."

©2014 Elizabeth E. Hogue, Esq.  All rights reserved.

It's a shame that the few abusers out there are hurting the industry.  Our response has been to create products to help home health agencies expand their business.  We provide software for managing care transitions and for adding an ongoing home care (non-medical / private duty) to a home health practice.   Two free white papers are offerered below:

 

white paper describing care transition readmission avoidance opportunity     home care best practices

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Reeadmisison avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.

Topics: Home Care Industry, Elderly Care, Health Care Reform, Home Healthcare Delivery Management

CMS Readmission Penalties for Dummies

Posted by Ken Accardi on Mar 13, 2014 11:45:00 AM

Have you ever seen those books that teach information "for Dummies"?  I just went to the official website (www.fordummies.com,) and these were the titles displayed on the home page:

Readmission Penalties for Dummies

I'm not so much a "for dummies" kind of guy.  Do we really need the book, "Reality Television for Dummies?"  What's to understand?  And even if you just arrived from another planet and wanted to understand reality TV, would you really read a book about it?  How about "Deleting Facebook Friends for Dummies?"   I'll admit that I don't know off the top of my head how to delete Facebook friends, but couldn't I just Google it?

CMS Readmissions Penalties Explained

Since we provide software for managing care transitions to help avoid readmissions, I thought that it would be great to do a blog article to explain the CMS Readmission Penalties.  So I went to the source on the Committee for Medicare and Medicaid Services (CMS) web site (click here to see it) and to be I honest that after a while, I wished that I could go buy the "for dummies" version.  

Here's what I've been able to find out, so far:

  • The penalties are in the form of "reduced Medicare payments" from CMS
  • In the first year the penalties can be up to 1% of payments
  • The program went into effect on October 1, 2012
  • Hospitals were measured on their readmission rates for three diseases:
    • Heart Attack (Acute Myocardial Infartion [AMI])
    • Congestive Heart Failure (CHF)
    • Pneumonia
  • The penalties for the 1st year were approximately $280M and over 2,000 hospitals received penalties (reference from Kaiser)
  • The second year of penalties are expected to be $227M (another reference from Kaiser)
  • Here's where it gets less clear:
    • There's a very nice article on the site of the Center for Healthcare Research and Transformation that says that the penalties go up to 2% in the second year and 3% in the third year, and that the disease states increase in the 3rd year to include Chronic Obstructive Pulmonary Disorder (COPD) coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA) and “other vascular” surgical procedures (reference from chrt.org)
    • If this is true, I don't understand why Kaiser predicts a drop in the penalties for year two?
    • The CMS site referenced above also talks about COPD but then lists elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) as opposed to CABG and PTCA.
I'm committed to figuring this out and will correct this post when I get to the bottom of it.  If you can help me, please comment below!  Thanks!
Readmission Avoidance Software
Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Reeadmisison avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.

Topics: Readmissions, Care Coordination, Care Transitions, Avoidable Readmissions

5 Warning Signs of Home Health Agency Start-up Failure

Posted by Ken Accardi on Mar 10, 2014 5:36:00 PM

We recently published a piece called The 7 Habits of Highly Successfull Home Care Agencies that shared our top observations of consistent practices that we see in agencies that are thriving.  My mentor and good friend Ginny Kenyon, from Kenyon Home Care ConsultingGinny Kenyon Home Care Consulting (www.kenyonhcc.com), went in the opposite direction with her most recent post, entitled, Sink or Swim: 5 Reasons a Home Health Startup Signals SOS.  It's a great article that I highly recommend that you read.  Ginny doesn't market her services too aggresively because she wants to focus on educating you with her blog.  However, if you are noticing these warning signs in your agency, then I highly recommend that you contact Ginny.

5 Warning Signs of Home Health Agency Start-up Failure

Here are the 5 warning signs:

  1. No Business Plan or Budget
  2. No Operations Plan or Procedure Manual
  3. Sales and Marketing Efforts Don't Exist - Or They Don't Work
  4. No Clients or Patients after 3 MonthsHome Care Failure
  5. Nothing Sets You Apart from the Competition

What to do next?

 Here's the plan:

 Home Care Success

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Reeadmisison avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.

Topics: Home Care Entrepreneurship, Home Care Best Practices, thought leadership, Home Care

US Health Care not measuring up on Life Expectancy and Cost

Posted by Ken Accardi on Mar 5, 2014 4:12:00 PM

Below is a very interesting, yet quite sad, infographic about US Life Expectancy verusHealthcare Information Network health care costs.  The infographic comes from the Healthcare Intelligence Network (tm) (www.hin.com), which is a site that regularly produces outstanding and intesting content.  The original article, entitled InfoGraphic: The Failure of US Healthcare Spending, was written by Jackie Lyons and posted on March 5th, 2013.

THe bottom line is that despite spending more than any other country on health care, that US life expectancy doesn't even rank in the top 50.  A portion of the Infographic is shown below.  Please click on it to see the full graphic.

US Health Care failure in Life Expectancy versus Cost

Here at Ankota, we're trying to do our part to increase life expectancy and reduce health care costs by helping care providers who focus on avoiding hospitalizations.  Our software helps companies manage transitions of care to avoid readmissions after a hospitalization, and also helps manage home care (to enable elderly people to remain living in the comfort of their own homes.  The benefits are profound because avoided hospitalizations reduce cost and improve outcomes and quality of life. 

Click on the images below for informative free white papers on readmission avoidance and highly effective home care.

Care Transitions Free White Paper      Highly Effective Home Care

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Reeadmisison avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.

Topics: Health Care Reform, thought leadership, Home Care Blogs

Subscribe to Email Updates

About Ankota

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Reeadmisison avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.

Follow Ankota on Twitter!

twitter bird white on blue

New Module

Add content here.