Home Care Heroes Blog

Inappropriate Home Health Referrals and Billing Lead to Convictions

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.

Your Comments :