Ten Floridians Indicted in Medicare Home Health Fraud Scheme

April 10, 2014

HCAF strongly condemns healthcare fraud and supports the removal of bad actors from the home health industry.

Nine residents of Miami-Dade County and a resident of Hillsborough County have been indicted for their alleged participation in a $12.5 million Medicare fraud scheme.

On March 20, 2014, a federal grand jury in Miami returned a 59-count indictment charging Vicente Diaz, 39, Daniel Ocampo, 35, Elsa Capo, 71, Santiago Sepulveda, 79, Marta Curbeco, 67, Margarita Rodriguez, 72, Francisco Maysonet, 67, Pedro Peralta, 69, Amira Galan, 79, and Ana Rosa Santana, 77, for allegedly participating in a scheme to defraud Medicare by submitting false and fraudulent claims, and the payment and receipt of kickbacks in connection with a federal health care program, from approximately November 2011 to October 2013.

The allegations center on the operation of Marcialed and Sacred Health, two companies located in Miami-Dade County which were purportedly in the business of providing home health care to Medicare beneficiaries.

According to the indictment, Diaz controlled Marcialed and Sacred Health. Ocampo was for a time an officer of Sacred Health. Diaz and Ocampo offered and paid kickbacks and bribes to patient recruiters in return for referring beneficiaries to serve as patients so that Marcialed and Sacred could bill Medicare for home health services that were not medically necessary and were not provided. Curbeco, Rodriguez and Peralta solicited and accepted kickbacks and bribes in exchange for referring beneficiaries to serve as patients of Marcialed and Sacred Health. Capo, Sepulveda, Curbeco, Rodriguez, Maysonet, Peralta, Galan, and Santana are Medicare beneficiaries who solicited and accepted kickbacks in return for agreeing to serve as patients of Maricaled and Sacred Health so that the companies could bill Medicare for home health services that were not medically necessary and were not provided.

The indictment alleges that the defendants falsified, and caused to be falsified, records to document the receipt of home health services from Marcialed and Sacred Health that were not provided and were not medically necessary. Diaz and Ocampo violated Medicare rules and regulations by offering and paying kickbacks and bribes to patient recruiters in exchange for the referral of beneficiaries to Marcialed and Sacred Health. Diaz and Ocampo then caused Marcialed and Sacred Health to submit false and fraudulent claims seeking payment from Medicare for the home health services which had purportedly been provided to beneficiaries, when in truth the services had not been provided and were not medically necessary. The indictment alleges that as a result of the fraudulent claims, Diaz and Ocampo caused Medicare to pay approximately $7,809,243 to Marcialed and $4,694,834 to Sacred Health.

The indictment alleges that Diaz, Ocampo and other conspirators used the money fraudulently obtained from Medicare for their personal use and to further the fraud. The indictment seeks forfeiture of two properties and four Mercedes vehicles.

Mr. Ferrer commended the investigative efforts of U.S. Postal Inspection Service, HHS-OIG, and the FBI and was brought as part of the Medicare Fraud Strike Force. This case is being prosecuted by Assistant U.S. Attorney Eric E. Morales.

An indictment is only an accusation, and a defendant is presumed innocent unless and until proven guilty.

OIG Study on Face-to-Face Recommendations to CMS: Standardized Form, Physician Education, Increased Oversight

April 10, 2014

The Office of Inspector General has published a study on the Medicare Home Health Face-to-Face (F2F) documentation requirement which highlights several solutions home care providers have suggested to improve compliance.

The study looked at 644 F2F encounter documents to analyze to what extent the documents confirmed encounters and contained the required elements as set out by CMS. The study sought to do three things:

  1. Determine the extent to which physicians who certified home health care documented the face-to-face encounters,
  2. Describe the nature of face-to-face documentation, and
  3.  Assess CMS’s oversight of the face-to-face requirement.

In addition, OIG interviewed the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to describe how they ensure that home health agencies met the face-to-face encounter requirements. The Office also reviewed guidance documents and policies from CMS or the HH MACs about monitoring the face-to-face requirement.

Read more in the Member’s Only section of HCAF’s website

Want access to this content? Join the premier organization representing the home health industry in Florida! The Home Care Association of Florida represents over 700 Florida home health care providers and vendors to the home care industry. HCAF strives to be the foremost resource and advocate for Florida’s home care industry and the patients our members serve. The Association is an active voice which continually interacts with state and federal lawmakers, regulatory agencies and fiscal intermediaries to interpret, challenge or support regulations that affect the home health care industry. We can help you stay in the race and get ahead of the pack!

HCAF Members Attend Annual Legislative Day at the Capitol – Important Meetings Lead to Steps that Would Eliminate the Home Health Quarterly Report

April 4, 2014

HCAF Advocates

On Wednesday, HCAF Members took to the Florida Capitol in order to lobby the State Legislature to take steps that would improve the home care industry in our state. The group of home health professionals, including a strong team sent by BAYADA Home Health Care, met with over 60 legislators to discuss eliminating or lowering the frequency of the home health quarterly report, raising the Medicaid Private Duty Nursing rate for Licensed Practical Nurses, and making sure any new framework for telemedicine includes home health nurses.

HCAF Board Member Lee Dobson and Nicole Walters, both of BAYADA Home Health Care meet with Sen. Wilton Simpson (R-Trilby).

HCAF Board Member Lee Dobson and Nicole Walters, both of BAYADA Home Health Care meet with Sen. Wilton Simpson (R-Trilby).

The day ended an a high-note, with the Senate Rules Committee adding an amendment to Senate Bill 1254 that would reduce the frequency of the home health quarterly report to twice per year. While HCAF will continue to seek full elimination of this time-consuming and obsolete report, this cuts the chances of providers missing the deadlines and being fined by half. Last year through their work at Legislative Day, HCAF advocates helped reduce the quarterly report fine from an instant $5,000 to $200 per day. It was these advocates’ meetings with members of the Senate Rules Committee (Senators Thrasher, Galvano, Richter, Simpson, Sobel, Margolis, and Negron) that paved the way for achieving this accomplishment. HCAF would also like to thank Senator Denise Grimsley for adding the measure to her bill. Furthermore, on the same day, both the House and Senate passed versions of the state budget including increases to Medicaid PDN LPN rates. Both chambers will seek to rectify some differences between each version before sending it to Governor Rick Scott for approval.

While we are proud of these accomplishments, we hope to have even more participation next year in order to tackle additional measures to improve home health in Florida! We will work to assist you in keeping close watch of future developments and will look to our members for assistance with increased advocacy in their legislators’ home districts.

In addition, HCAF was honored to have Representative Amanda Murphy (D-New Port Richey) as the keynote speaker at our Annual Legislative Briefing Dinner. Rep. Murphy spent ample time speaking and answering questions from members about the state of healthcare in Florida, how she expects home care to fit in, and effective ways of communicating with legislators. HCAF would like to thank Rep. Murphy for giving us ample time in the middle of her busy legislative session schedule!

From Left: Chris Lipson, HCAF Director of Government Affairs and Member Advocacy, Rep. Amanda Murphy (D-New Port Richey), HCAF Executive Director Bobby Lolley, HCAF Board President Anthony Clarizio

From Left: Chris Lipson, HCAF Director of Government Affairs and Member Advocacy, Rep. Amanda Murphy (D-New Port Richey), HCAF Executive Director Bobby Lolley, HCAF Board President Anthony Clarizio

Reminder: Home Health Quarterly Reports are Due to AHCA by April 15th

April 4, 2014

Home health agencies must submit a quarterly report by April 15th to the Florida Agency for Health Care Administration, otherwise non-compliant providers will be fined!

Keep in mind that HCAF successfully lobbied for the passage of Senate Bill 1094 which exempted some home health agencies, who meet certain criteria, from submitting the Quarterly Report. See AHCA’s Frequently Asked Questions to see if you are exempt. Fines were also reduced to $200 per each day late up to a maximum of $5,000 effective July 1, 2013.

By law, agencies must report the following information based on the agency’s patient census as of December 30, 2013:

  • Number of insulin-dependent diabetic patients receiving insulin injection services
  • Number of patients receiving home health services from the home health agency AND a licensed hospice provider
  • Total number of patients receiving home health services
  • The names and license numbers of nurses (RN’s or LPN’s) whose primary job responsibility is to provide home health services to patients and received remuneration in excess of $25,000 for the three months of the quarter

Providers can submit reports anytime between April 1 and April 15. For more information and instructions for submitting the report, click here to access the AHCA website or call the HCAF office at (850) 222-8967 or the AHCA Home Care Unit at (850) 412-4403.

Medical Clinic Owner and Other Patient Recruiters Sentenced for Roles in $8 Million Health Care Fraud Scheme

March 21, 2014

HCAF strongly condemns healthcare fraud and supports the removal of bad actors from the home health industry.

Several patient recruiters, including a medical clinic owner, were sentenced today for their participation in a health care fraud scheme involving Flores Home Health Care Inc., a defunct home health care company.

Lerida Labrada, 59; Mayra Flores, 49; and German Martinez, 36, all of Miami, were sentenced by U.S. District Judge Ursula Ungaro of the Southern District of Florida to serve 37 months, 24 months, and 24 months in prison, respectively.   In addition to their prison terms, all of the defendants were sentenced to three years of supervised release and ordered to pay between $200,000 and $400,000 in restitution.

On Jan. 7, 2014, Labrada pleaded guilty to conspiracy to commit health care fraud, and Flores and Martinez pleaded guilty to conspiracy to defraud the United States and receive health care kickbacks.

According to court documents, the defendants worked as patient recruiters for the owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries.   Labrada also owned and operated a Miami medical clinic that provided fraudulent prescriptions to patient recruiters and to the owners and operators of Flores Home Health.

The defendants would recruit patients for Flores Home Health and would solicit and receive kickbacks and bribes from the owners and operators of Flores Home Health in return for allowing the company to bill the Medicare program on behalf of the recruited Medicare patients.   These Medicare beneficiaries were billed for home health care and therapy services that were not medically necessary and/or were not provided.

From approximately October 2009 through approximately June 2012, Flores Home Health was paid approximately $8 million by Medicare for fraudulent claims for home health services.

The case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.   This case is being prosecuted by Trial Attorney A. Brendan Stewart of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Source: OIG

New York Times Article Depicts Major Pitfalls in Managed Long-Term Programs

March 14, 2014

While the Florida Managed Long-Term Care (LTC) program is still in the roll-out stage, the New York Times released an article March 6th detailing the difficulties experienced by patients and and the governments in other states with established care systems.

Many states, including Florida, have seen costs for LTC explode in the last few years due to a rapidly aging population. While this move to manages care could benefit home care, ending the long stranglehold the nursing home industry has had on caring for Medicaid patients, the article reveals many Americans who are unable to qualify for any kind of care in a way for managed care entities to preserve profits.

HCAF is closely monitoring the Managed Long Term Care program in Florida and will continue to advocate for the use of home and community based care. Solving the problems associated with our State’s growing elderly population will not be easy, but we continue to stress the importance of serving seniors in their preferred setting, which is also the most cost-effective: their home.

Click here to read the New York Times Article.

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President’s Budget Includes Provisions for Home Health Copays, Additional Payment Cuts for Post-Acute Care Providers

March 7, 2014

obama-budgetPresident Obama released his 2015 budget proposal earlier this week, laying out his agenda and legislative priorities for the coming year. Two of the provisions included in President Obama’s FY15 budget are similar to previous proposals that would be of great concern to the home health community.

Specifically, President Obama’s budget once again calls for the introduction of a home health copayment – as well as further cuts to post-acute care providers, including home health care.

President Obama’s budget also includes provisions for a bundled payment program for post-acute providers, as well as value-based purchasing for post-acute care providers. The specifics of these four proposals are included below:

Introduce Home Health Copayments for New Beneficiaries

This proposal would create a co-payment for new Medicare beneficiaries (those who become eligible for Medicare in 2018 and thereafter) of $100 per home health episode, starting in 2018. Consistent with MedPAC recommendations, this co-payment would apply for episodes with five or more visits not preceded by a hospital or inpatient post-acute stay. [$820 million in savings over 10 years].

Read more in the Member’s Only section of HCAF’s website

Want access to this content? Join the premier organization representing the home health industry in Florida! The Home Care Association of Florida represents over 700 Florida home health care providers and vendors to the home care industry. HCAF strives to be the foremost resource and advocate for Florida’s home care industry and the patients our members serve. The Association is an active voice which continually interacts with state and federal lawmakers, regulatory agencies and fiscal intermediaries to interpret, challenge or support regulations that affect the home health care industry. We can help you stay in the race and get ahead of the pack!

Learn more about becoming a member!

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Obama Administration Further Delays Employer Mandate for Certain Employers – Clarifies Use of Volunteers

February 28, 2014

health_care_reform_imageThe Obama administration recently issued an IRS Final Rule that further delays parts of the Affordable Care Act requiring employers to provide health insurance for their workers. Employers that have fewer than 100 full-time workers will have one extra year – until 2016 – before the employer mandate takes effect. Companies that have fewer than 50 workers are already exempt from the requirement to cover their employees.

Under the rule, employers of more than 100 full-time employees will need to cover 70 percent of their full-time employees in 2015 and 95 percent in 2016 or later or face a penalty. Obama administration officials said the change was a response to complaints about the law’s definition of a full-time worker as one who works 30 hours per week, rather than the conventional definition of a 40-hour work week.

HCAF has long endorsed changing the definition of “full-time worker” from 30 hours a week to 40 hours.  HCAF has worked with the National Association of Home Care and Hospice (NAHC) to acheive this goal. Legislation to change that definition is pending in both the House and Senate.

HCAF and NAHC’s leadership led efforts to educate lawmakers on the consequences that the Employer Mandate would have on access to home health and hospice services, which helped to lead to an earlier decision in July to delay enforcement of the Employer Mandate and influenced the additional delay set out in this latest rule.

Analysis by NAHC staff found that the following changes will apply under the new ruling:

Read more in the Member’s Only section of HCAF’s website

Want access to this content? Join the premier organization representing the home health industry in Florida! The Home Care Association of Florida represents over 700 Florida home health care providers and vendors to the home care industry. HCAF strives to be the foremost resource and advocate for Florida’s home care industry and the patients our members serve. The Association is an active voice which continually interacts with state and federal lawmakers, regulatory agencies and fiscal intermediaries to interpret, challenge or support regulations that affect the home health care industry. We can help you stay in the race and get ahead of the pack!

Learn more about becoming a member!

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Free Exposure to Florida Discharge Planners

February 7, 2014
CCDirectoryPic
BACK BY POPULAR DEMAND
The first three editions of HCAF’s Member Directory and Referral Guide proved to be so valuable that HCAF will publish its fourth edition during the summer of 2014!
Directories will be sent to every hospital discharge department in Florida, increasing your ability to get referrals. In fact, we have discharge planners calling and asking us to send them additional copies!
Agencies will be listed by service area and alphabetically. Each agency’s profile will include contact information (address, phone, fax, website, license number), payer source(s) accepted, service area, type of services provided and an “accredited by” field. Please click on the following link that pertains to your HCAF membership status before March 11, 2014 to make sure your company’s demographic and service information is accurate and to provide us with any changes.
If you have any questions or changes to your listing after viewing your profile on the above links, please contact HCAF at (850) 222-8967 or send an email to Julia Heath at jheath@homecarefla.org.
Every HCAF member will receive a complimentary directory with the option to purchase more copies. The 2014 Member Directory and Referral Guide is the perfect opportunity for home care agencies to be front and center for discharge planners, but the deadline to appear in the directory is soon. So please don’t delay! Make sure you join HCAF, renew membership or update your member profile by March 11, 2014.

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CMS Develops New Billing Codes for Chronic Care Management Services

January 31, 2014

The 2014 final rule for the Medicare physician fee schedule included the addition of a new payment code for chronic care management to begin in 2015. The new code will allow reimbursement for non-face to face time physicians spend managing patients with multiple chronic conditions that are not reimbursed under the current Evaluation and Management codes physicians bill for office visits. These codes are in addition to the recently added Transition Care Management codes (TCM 99495-99496), which also reimburses physicians for non-face to face time association with transitioning patients to the community.

In the final rule, the Centers for Medicare& Medicaid Service (CMS) agreed to assign only one code for chronic care management services rather than two separate codes, and shorten the time frame for providing the service from 60 minutes per 90 days to 20 minutes per 30 days. The new code will read as follows:

“Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days”

The final rule sets the scope for chronic care management services to include:

  • 24-hour-a-day, 7-day- a-week access to address a patient’s acute chronic care needs.
  • Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
  • Care management for chronic conditions including systematic assessment and development of a patient centered plan of care.
  • Management of care transitions within health care.
  • Coordination with home and community based clinical service providers.
  • Enhanced opportunities for a patient to communicate with the provider through telephone and secure messaging, internet or other asynchronous non face-to-face consultation methods.

CMS accepted comments on the following proposed standards that it expects physicians to comply with in order to furnish and receive reimbursement for chronic care management services:

  • The practice must be using a certified Electronic Health Record (EHR).
  • The practice must employ one or more advanced practice registered nurses or physician’s assistants.
  • The practice must be able to demonstrate the use of written protocols by staff participating in the furnishing of services.
  • All practitioners involved in the furnishing of chronic care management services must have access at the time of service to the beneficiary’s EHR.

CMS intends to issue its final standards in the 2015 Physician Fee Schedule rule.

CMS was clear in the final rule that the TCM service codes and the Care Plan Oversight codes for home health and hospice (G181- G0182)  may not also be billed during the time period when Chronic Care Management services are billed.

To view the final rule, please click here.

Source: NAHC

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