The 8 th Annual NEHCC Conference and Trade Show

Transcription

1 April 26, 2018 The 8 th Annual NEHCC Conference and Trade Show Home Health and Hospice Audits and Investigations: Perspectives from a Federal Agent and a Former Health Care Fraud Prosecutor PRESENTED BY David S. Schumacher, Partner Hooper, Lundy & Bookman, P.C. and Jenette Hernandez, Special Agent U.S. Department of Health and Human Services Office of Inspector General, Office of Investigations

2 AGENDA 1. Background/Enforcement Landscape 2. Recent Criminal and Civil Cases 3. Case Study: At Home VNA Case 4. Audit Basics

3 3 Facts and Figures 2016: ~$3.2 trillion spent on health care (>5.8%) Home health care: $100 billion industry ~$173 billion by million Medicare benes receive home health care ~ 12,400 HHAs (increase from ~4,600 in 1994) MassHealth spent $750M on home health care in 2016 (35% increase) 3

4 4 Facts and Figures Combatting Fraud & Abuse Estimates: tens of billions lost to fraud each year ~$41 billion of Medicare funds paid improperly 2017 (UPDATE) Government recovered ~$2.6 billion in health care fraud cases 967 new criminal health care fraud investigations Criminal charges filed in 439 cases 639 defendants convicted 948 new civil investigations 3,244 individuals/entities excluded from Medicare 4

5 5 Who is Investigating? Federal DOJ/USAO (Criminal and Civil) HHS-OIG FBI Whistleblowers/Qui Tam State AG/MFCU MassHealth (L/T Services and Supports (LTSS) TPA Optum) State Auditor (OSA) Division of Professional Licensure Local District Attorneys Commercial SIUs and regular meetings with USAO 5

6 6 Who is Investigating? Federal and State Contractors Medicare Administrative Contractors (MACs) Recovery Audit Contractors (RACs) Program Safeguard Contractors (PSCs) Medicaid Integrity Contractors (MICs) Zone Program Integrity Contractors (ZPICs) Unified Program Integrity Contractors (UPICs) o Meant to consolidate MICs, ZIPCs, and PSCs Quality Improvement Organizations (QIOs) Medicare Advantage Plans Medicaid Managed Care Plans Medicaid Integrity Institute Healthcare Fraud Prevention Partnership 6

7 7 How are They Investigating? Sources Qui Tam/Whistleblowers Data Mining Media Reports Methods Search warrants/wires/subpoenas Wild card: payment suspension Credible allegation of fraud NO appeal until overpayment determination 7

8 8 Recent Criminal Cases 8

9 9 Recent Criminal Cases Current DOJ direction: aggressive as ever Examples Texas Michigan Miami New Orleans TLC Healthcare Services (Chicago) 9

10 10 Recent Civil/False Claims Act Cases False Claims Act basics Example: Chemed/Vitas More activity in hospice than home health of late Recent signs of pullback? 10

11 11 HHS-OIG Published Risk Areas 2017 Work Plan Home Health Compliance with Medicare Requirements (10/17) High error rate (~50%, $9 billion) Patients not homebound/don t require skilled services Review of home health PPS & medical review of documentation 11

12 It couldn t happen here, right? 12

13 13 Massachusetts AG Criminal Cases Compassionate Homecare Harmony Home Health Care Lifestream Healthcare Civil case: Maxim Healthcare Services 2016 new regulations Prior authorization Documented F2F Certifying physicians cannot be on staff/under contract with HHA) 13

14 14 Case Study: At Home VNA Investigation At Home VNA HHA in Waltham, MA Administrator: Michael Galatis DON: Janice Troisi Medical Director: Spencer Wilking, MD 14

15 15 Case Study: At Home VNA Investigation CMS Investigation Data Mining Records Request SVRS HHS-OIG Investigation Claim Review Interviews DOJ Investigation Interviews Grand Jury 15

16 16 Case Study: At Home VNA Investigation Key Findings Wellness clinics to recruit healthy patients Manipulated OASIS forms Medical director robo-signed POCs PCPs unaware of services No F2F Ignored complaints from nurses, doctors, families 16

17 17 Case Study: At Home VNA Investigation Results Galatis: 7+ years incarceration, $7M restitution Troisi: 3 years incarceration Dr. Wilking: probation, fine Cooperated Collateral impact 17

18 18 Common Threads/Takeaways Facts likely to get you in trouble: Large outliers Paying for referrals False documentation Failure to perform F2F What matters to prosecutors Patient harm Greed Tone at the top Compliance 18

19 19 Prepare for an Audit 19

20 20 Anticipate (and Avoid) Audits Familiarize yourself with CMS policies Establish an Audit SWAT Team Designate a point of contact Implement tracking process Develop policies and procedures Review recent CMS and MassHealth audits Proactively audit Engage outside billing specialist; annual coding accuracy review 20

21 21 What To Do If You Are Audited/Investigated 2 Key Threshold Questions Who is investigating? Criminal? Federal, state or commercial? Criminal or civil? What is the scope of the audit/investigation? 21

22 22 Responding to an Audit Engage counsel Calendar deadlines Take the time to get it right on the front end Avoid unprepared interviews Gather information about preliminary findings Cure documentation issues Exit Conference: be careful what you sign Maintain copies of all documents provided 22

23 23 Appeals Process 6 stages Rebuttal to MAC demand letter Redetermination (MAC) Reconsideration (QIC) ALJ hearing Departmental Appeals Board/MC Appeals Council District Court Takes years, but worth it (>60% success rate) 23

24 Conclusion/Questions? David S. Schumacher Mr. Schumacher is managing partner of HLB s Boston office. Prior to joining HLB, Mr. Schumacher was deputy chief of the Health Care Fraud Unit in the U.S. Attorney s Office for the District of Massachusetts. He focuses his practice on criminal defense, fraud & abuse, and health care enforcement actions. Hooper, Lundy & Bookman, P.C. 470 Atlantic Ave. Suite 1201 Boston, MA (617) dschumacher@health-law.com