Healthcare at Home: The Rowan Report

“Hospices that think they do not have a Notice of Eligibility problem are in trouble.”  

The CEO of software developer MedTranDirect was anxious for us to get this message out. Yes, they have software to sell that helps with the NOE crisis but that was not Ellie Robison’s focus during our recent conversation. She told us that, in the process of promoting her company’s NOE Tracker software with prospective clients, she has noticed widespread misunderstanding, which will become profoundly expensive, if it hasn’t already.

“We had a client who was confident there was not a problem and we pushed him to let us take a closer look. We found they had $10,000 in penalties, just in the last 3 months.” The problem, she explained, is that the onus to report NOE penalties falls on the provider. Neither the provider’s MAC or CMS itself has to expend the effort to look for them. [The “new rules” that hospice organizations must learn to determine and manage NOE penalties are described in detail in this article.]

 

Here are the new rules hospices must learn:

1. To determine a potential penalty, the hospice biller must look up every claim in the CMS DDE database and compare its NOE received date with its patient admission date.
   1. If the difference is less than 5, the NOE was filed timely and the hospice may claim payment for every hospice day.
   2. If the difference is greater than 5, the NOE was filed late and the hospice may not bill for the days before the NOE was received.
   3. If a claim is sent, it will be paid, with or without a late NOE.
   4. It is important to note that there may be a penalty whether or not you receive a “RTP” (return to provider notice) from CMS. RTPs are sent only if there are errors, not to notify you that the NOE was late.
2. To manage a penalty, the hospice biller must self-report the days from start-of-care to the date the late NOE was received.
   1. If the biller properly self-reports the penalty on the first submitted claim, the MAC will deduct payment for those days when paying the claim and the hospice’s balance will be even.
      “Like the IRS,” Ellie Robison told us, “CMS expects hospices to voluntarily report penalties on the first claim submitted for the patient. These penalties are reported as ‘unbilled days.’ When Medicare pays the claim, the payment will be for the net days billed that month, with the penalty days automatically subtracted.”
   2. If the biller does not self-report a late NOE, the MAC will pay the claim in full and the hospice creates a liability for the amount of the penalty.
      “Just as the IRS only taxes you for the income you report, even if you leave some off, your MAC will pay you for your unbillable days if you do not report them,” Ms Robison continued. “Also like the IRS, if CMS discovers you have not been reporting these penalties, they will find them during an audit and make you pay at that time, with additional penalties and interest.”
      1. The liability exists whether or not the NOE penalty is reported or paid.
      2. Unpaid penalties will turn up during CMS audits and collected against future claims.
      3. Additional interest and penalties will be applied to collection amounts.
      4. Future scrutiny will be more severe. Returns will be examined for other errors, with the possibility that auditors will determine criminal intent and apply criminal penalties.

The CEO wrapped up our conversation and her lessons with one final admonition. “If hospices are smart, they will avoid this by reporting the penalty accurately the first time.”

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

Schaumburg, IL — July 20, 2016 — Procura announced today that it has completed testing and launch of functionality and integration to fully support Texas Medicaid’s Electronic Visit Verification (EVV) mandate. The functionality has been fully implemented into Procura’s cloud-based ContinuLink product.  Electronic Visit Verification is mandated for selected Texas Health and Human Services Commission (HHSC) and Texas Department of Aging and Disability Services (DADS) programs, as well as for certain Managed Care Organizations (MCOs). [Details are provided on need for healthcare at home Medicaid providers in Texas to use this ContinuLink product to meet EVV requirements.]

With many home health customers in Texas using one of its EMR and scheduling systems, an official company news release stated, Procura’s support of the EVV Mandate permits current and future customers to deploy its ContinuLink system as their enterprise management software for the programs that require it.

“We are pleased to have completed the development and launch for Texas Medicaid’s EVV requirement,” stated Chris Junker, Procura’s CEO, “as we have a number of key accounts that were operating legacy or rudimentary systems for Texas EVV until now.  These customers, and new customers in Texas, will now be in a position to consolidate on the ContinuLink platform in order to take advantage of its industry leading operational, clinical, and financial management capabilities, which we deliver in a web-based solution.”

The primary benefit of this development for home health providers in Texas using and/or considering ContinuLink is the ability to use a single, end-to-end system to handle Medicaid cases rather than having to utilize one of the outside EVV systems approved by Texas DADS.

About Procura Healthcare Software
Procura is a provider of enterprise and cloud based software to home health agencies, community care agencies and Hospice and residential care agencies in the US, Canada and Australia. Procura products are used daily at more than 4,200 customer sites that are managing care for over 3 million patients. More than 45,000 office staff and 500,000 caregivers deploy Procura products, supporting more than 45,000 residential beds.

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

 

Cathy Sorenson was skeptical but desperate. With an average daily census over 400 but a profit margin at a barely surviving level, the President and CEO of Home Healthcare Hospice and Community Services in Keene, New Hampshire, frankly rated her agency’s overall performance as ‘mediocre’ and was ready to try anything to draw the best out of her staff. What she wound up trying, beginning in August, 2015, sounded impossible to her at first: one hundred percent utilization review for clinical management of home health.

Designed by Arnie Cisneros, PT, President of Home Health Strategic Management, the program he has dubbed SURCH (Service Utilization Review for Care in the Home) was installed at HHSM in July and kicked off agency-wide in early August. Before long, the agency’s CMS star rating started climbing. From three stars since the inception of the rating system, it crept up to 3.5 in October, then to 4 stars in November. By January of this year, the agency reached the coveted 5-Star rating. Simultaneously, their case-mix weight rose from an anemic .81 to a remarkable 1.37, virtually doubling reimbursement per PPS episode from under $2,200 to over $3,600. [Rowan provides details about HHSM’s transformative use of the SURCH program and its excellent results, including undertaking 100% utilization reviews per patient at start of care and at discharge. Staffpersons’ initial concerns about the SURCH program and eventual receptiveness to it are noted in this article.]

 

By April, word of the HHSM transformation had spread. The VNAA awarded the agency its 2016 “Innovative Model Award” during its annual meeting in Miami. In accepting the award for her agency, Ms. Sorenson said, “We tried to do it by ourselves but couldn’t reach the levels of efficiency, value, or Medicare compliance that the S.U.R.C.H. management produces. This process has revitalized and changed our culture in such a way, no one wants to go back to how we used to work.”

Curiously, Ms. Sorenson told us, her average daily census reduced by half, from approximately 400 to 200. And yet, gross revenue is up, which begs the question, “What is SURCH, and how does it accomplish this kind of transformation?” This is how the CEO describes the HHSM story.

100% Utilization Review
Every field nurse completes every OASIS assessment in the presence of the patient, during a telephone consultation with a UR nurse in the office. The goal is to design a custom care plan, not one that follows an agency protocol for the average patient but one that calls for the exact number of visits this patient is likely to need. Where the agency average had been 12 or more therapy visits for a joint replacement patient, it is now from five to nine, and outcomes have improved. UR nurses continue to review every case with every nurse throughout each episode of care.

“We had been auditing start-of-care OASIS assessments but not resumption or discharge,” Ms. Sorenson explained, “and we did the audits long after the visit ended. That practice never made a big difference in quality, consistency, or accurate documentation.” In order to make this new policy work, she decided they had to make it a mandatory process for all frontline staff. There was some initial pushback but, in the words of Arnie Cisneros, “Pushback is a phase.”

From Doubt to Enthusiasm
His platitude came true for HHSM. “Hospital nurses get used to carrying out care plans designed by someone else,” he says. “Home care nurses can too.” HHSM nurses initially resisted, thinking something was being taken away from them but, Ms. Sorenson noticed, they finally saw that they were being relieved of a burden and they grew to appreciate it. Nurses found they were getting better at the OASIS phone consultation. Where it initially took 20 minutes, they now report it takes about five.

“Initially, it was, ‘You’re telling me how to deliver care, and it’s not the way I have always delivered care.’ But before long, they saw the benefits and embraced the process. We only lost two staff members, one OT and one PT, and I was OK with that because those individuals with that level of disagreement, would have needed a lot of micro-management.”

The SURCH program is designed to be effective, not easy, Cisneros admits, but it does produce results in a short period of time. “Legacy methods of care will not work under healthcare reform,” he repeats in every presentation and conversation until it becomes a mantra. “The days of ‘3week9’ are over if you intend to be around as ACOs, CJR bundles, and value-based payment systems spread from state to state. If you lay out a 60-day care plan, you fix it in your mind that you have 60 days to get this patient independent. Start with a 30-day care plan and extend it only if you have to. Do you know what ACOs and hospitals in CJR bundle programs say about a two-episode case with 30 visits? They say, ‘I hope you made a lot of money because that’s the last patient you’re getting from us.'”

Patient Outcomes Create Financial Outcomes
In less than a year, the transformation at HHSM is nearly complete. They have achieved:

• 100% deny-proof documentation;
• Average length of stay of 30 days;
• Hospital readmission rate has dropped from 15% to 4%;
• Case-mix average is 1.37, up from .81

SURCH procedures that enable results like these include quick response following hospital discharge: early the next morning for most patients, same day for CJR patients; front-loading visits in order to achieve quicker patient independence; and ordering PT and OT services for nearly every patient.

Initially, Ms. Sorenson admits, some physicians, one New Hampshire hospitalist in particular, were uneasy with routine PT and OT services for every patient, reasoning, “They did not have therapy services before this hospitalization and they were not admitted for a therapy-related diagnosis.” “Yes,” she answers them, “but they’ve been in a hospital bed for four days. Our assessment indicates a fall risk that did not exist before.”

Ms. Sorenson was concerned that such a dramatic improvement over a short period of time would raise MAC eyebrows. “I’m sure they would like to find that we are manipulating the system somehow,” she smiles, “but when they see our documentation, our bullet-proof documentation, they quietly pay every claim.”

 

About That Census Drop
So, with all this success, we had to ask, why is your census half what it used to be? Cathy Sorenson’s explanation is steeped in healthcare reform era thinking. “Our admissions have remained steady,” she points out, “but we are no longer wasting payer money by keeping them on service for two and three PPS episodes. We are able to help them meet their goals in 30 days most of the time. That has slashed our per-episode costs more than it has reduced our revenue. So, think about it, the patients are better off, the hospitals and ACOs are happy, the payers are happy, and we are making more money. Don’t worry, as word spreads about what we are doing, and referral sources see our 5-star rating, our census will bounce back.”

The Centers for Medicare and Medicaid Services has announced the conclusion of its five-year effort to validate certified providers. Is this cause for a “Phew” or a “Uh-Oh?”

The answer, according to longtime home health financial advisor Jim Plonsey, President of is a definite “Uh-Oh.”

“In their June 2 bulletin (reprinted in its entirety below), they said they will start immediately to re-validate every certified provider, from hospitals to physicians to post-acute providers,” explained Plonsey. “But watch out. This round will be worse, and you have to read between the lines to see why.” [This article presents details on the revalidation process for healthcare at home certified providers and about the recent [2016] second round of revalidation by Medicare.]

 

Among the cautions he has detected are:

1. Claims from re-validated home health agencies will be denied payment if the referring physician is not re-validated. 
   “This is normally not a major problem,” Plonsey clarified, “but imagine what will happen if you have a referring physician who is months away from retirement. He or she may not bother to re-validate, but may continue to refer patients to you. By the time you get your denial notice, he or she is long gone and you are out of luck. Just like PECOS, you had better know where your physicians stand.”
2. The second round of validations will not proceed in the same order as the first round. In other words, if your validation occurred late in the previous 5-year effort, you cannot assume you have five years before your turn comes up again.
   Plonsey again: “They said they are going to randomize the order of the re-validations. You could be summoned this year even though you were validated last year.”
3. You will receive an email letting you know two to three months in advance that your re-validation date has been scheduled.
   “But you do not have to wait to receive that email,” Plonsey told us. “Your date will be posted on a special CMS web page six months in advance. You cannot respond until 60 days before your date but you can at least know the date six months early. If your date is more than six months out, the web site will tell you that your date is ‘To Be Determined.’ That web site, data.cms.gov/revalidation, will be updated every 60 days, so you should set up your series of calendar reminders now.”

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REVALIDATIONS

CMS has completed its initial round of re-validations and will be resuming regular revalidation cycles. In an effort to streamline the re-validation process and reduce provider/supplier burden, CMS has implemented several revalidation processing improvements.

For more information see MLN Matters® Number: SE1605 or review the March, 2016 Revalidation Cycle 2 MLN Connects Call.

Why must I revalidate?
Section 6401 (a) of the Affordable Care Act:

• Established new screening requirements for new and existing providers/suppliers
• Required all existing providers/suppliers to be revalidated under new screening requirements
• Reinforces the revalidation requirements at 42 CFR §424.515

When Must I revalidate?
Revalidations are due on the last day of the month (i.e.: June 30, 2016, July 31, 2016, August 30, 2016). You are expected to submit your revalidation application by this date.  Generally, this due date will remain with you throughout subsequent revalidation cycles.
Due Dates are posted on Data.CMS.gov/revalidation – lists all currently enrolled providers/suppliers and their revalidation due date

• Due Dates are updated every 60 days at the beginning of the month
• Due Dates are listed up to 6 months in advance
• Due Dates that are not yet assigned will be listed as TBD – To Be Determined (more than 6 months until your due date)
• Durable Medical Equipment Prosthetic and Orthotic Supplies (DMEPOS) suppliers will not display a due date; instead, DMEPOS suppliers will receive communication from the National Supplier Clearinghouse (NSC) identifying when their revalidations are due
• Search by individual provider or organization
• See providers reassigned to your group and when they are due to revalidate
• Download the entire revalidation data set in different formats (i.e., CSV, PDF, XLS, XLSX or XML)

Revalidation Notices sent via email/mail

• Your Medicare Administrative Contractor (MAC) will send a revalidation notice within 2-3 months prior to your revalidation due date
• Will identify organizations to which individual providers reassign benefits
• Sent to email addresses reported on your prior applications, or
• Sent via postal mail to at least two of your reported addresses (Sample A/B MAC Letter and DMEPOS Letter)
  • Correspondence address
  • Special Payments address and/or
  • Your primary practice address

NOTE:  If you are within 2 months of the listed due date on Data.CMS.gov/revalidation but have not received a notice from their MAC to revalidate, you are encouraged to submit your revalidation application.
Do not submit a revalidation if:

• You have not received an email/mailed letter from your MAC requesting you to revalidate (request from NSC for DMEPOS suppliers)
• Due date is not listed on data.CMS.gov/revalidation
• These unsolicited revalidations will be returned

NOTE: If your intention is to submit a change to your provider enrollment record, Submit a ‘change of information’ application using Internet Based PECOS or the appropriate CMS-855 form.

How do I revalidate?
Revalidate your entire enrollment record, including:

• All active practice locations
• Current reassignments
• See the Revalidation checklist

The most efficient way to submit your revalidation information is via Internet Based PECOS. You can:

• Review information currently on file
• Update and submit your revalidation
• Electronically sign after uploading supporting documents; or print, sign, date and mail your paper certification along with supporting documentation

What happens if I don’t revalidate?
Submit a complete revalidation application by your due date, and respond on time to all related requests from your MAC to avoid:

• Possible hold on your Medicare payment
• Deactivation of your Medicare billing privileges

Deactivated providers will be required to submit a complete application to reactivate their enrollment

• Will maintain their original PTAN
• Reactivation date will be date of receipt of new complete application
• No payments will be made for the period of deactivation

Still have questions? Please view the Revalidation FAQs
Questions regarding your enrollment? Contact Your MAC

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

By Tim Rowan, compiler, editor and publisher of Home Care Technology Report

On June 22, Attorney General Loretta E. Lynch and Department of Health and Human Services Secretary Sylvia Mathews Burwell announced an unprecedented nationwide sweep led by the Medicare Fraud Strike Force in 36 federal districts, resulting in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $900 million in false billings.  Twenty-three state Medicaid Fraud Control Units also participated in today’s arrests.  In addition, the HHS Centers for Medicare & Medicaid Services (CMS) is suspending payment to a number of providers using its suspension authority provided in the Affordable Care Act.  This coordinated takedown is the largest in history, both in terms of the number of defendants charged and loss amount. [Key government players and offices are identified in this article, and it is noted that provisions in the Affordable Care Act have provided new tools and resources to fight fraud in federal health care programs. States very much involved in the Medicare Fraud Strike Force operation are identified in the second half of this article.]

 

Attorney General Lynch and Secretary Burwell were joined in the announcement by Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, FBI Associate Deputy Director David Bowdich, Inspector General Daniel Levinson of the HHS Office of Inspector General (OIG), Acting Director Dermot O’Reilly of the Defense Criminal Investigative Service (DCIS), and Deputy Administrator and Director of CMS Center for Program Integrity Shantanu Agrawal M.D.

The defendants announced today are charged with various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft.  The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and prescription drugs.  More than 60 of the defendants arrested are charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest-growing component of the Medicare program overall.

“As this takedown should make clear, health care fraud is not an abstract violation or benign offense – It is a serious crime,” said Attorney General Lynch.  “The wrongdoers that we pursue in these operations seek to use public funds for private enrichment.  They target real people – many of them in need of significant medical care.  They promise effective cures and therapies, but they provide none.  Above all, they abuse basic bonds of trust – between doctor and patient; between pharmacist and doctor; between taxpayer and government – and pervert them to their own ends.  The Department of Justice is determined to continue working to ensure that the American people know that their health care system works for them – and them alone.”

“Millions of seniors depend on Medicare for essential health coverage, and our action shows that this administration remains committed to cracking down on individuals who try to defraud the program,” said Secretary Burwell.  “We are continuing to put new tools and additional resources to work, including $350 million from the Affordable Care Act, for health care fraud prevention and enforcement efforts.  Thanks to the hard work of the Medicare Fraud Strike Force, we are making progress in addressing and deterring fraud and delivering results to help ensure Medicare remains strong for years to come.”

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided.  In many cases, patient recruiters, Medicare beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of submitting a total of approximately $900 million in fraudulent billing.

“The Medicare Fraud Strike Force is a model of 21st-Century data-driven law enforcement, and it has had a remarkable impact on health care fraud across the country,” said Assistant Attorney General Caldwell.  “As the cases announced today demonstrate, the Strike Force’s strategic approach keeps us a step ahead of emerging fraud trends, including drug diversion, and fraud involving compounded medications and hospice care.”

“These criminals target the most vulnerable in our society by taking money away from the care of the elderly, children and disabled,” said Associate Deputy Director Bowdich.  “The FBI is committed to working with our partners and the public to stop fraud and ensure that healthcare dollars are used to help the sick, and not line the pockets of criminals.”

“While it is impossible to accurately pinpoint the true cost of fraud in federal health care programs, fraud is a significant threat to the programs’ stability and endangers access to health care services for millions of Americans,” said Inspector General Levinson.  “As members of the joint Strike Force, OIG will continue to play a vital role in tracking down these criminals and seeing that justice is done.”

“DCIS, in partnership with our fellow federal investigative agencies, will continue to uncompromisingly investigate and bring to justice the people who perpetrate these criminal acts,” said Acting Director O’Reilly. “Their actions threaten to cripple our vital national health care industry, and place our citizenry at risk.  We will remain vigilant.”

“Taxpayers and Congress provided CMS with resources to adopt powerful monitoring systems that fight fraud, safeguard program dollars, and protect Medicare and Medicaid,” said Deputy Administrator and Center for Program Integrity Director Agrawal.  “The diligent use of innovative data analytic systems has contributed or led directly to many of the law enforcement cases presented here today.  CMS is committed to its collaboration with these agencies to keep federally-funded health care programs safe and strong for all Americans.”

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.  The Medicare Fraud Strike Force operates in nine locations and since its inception in March 2007 has charged over 2,900 defendants who collectively have falsely billed the Medicare program for over $8.9 billion.

Including today’s enforcement actions, nearly 1,200 individuals have been charged in national takedown operations, which have involved more than $3.4 billion in fraudulent billings.  Today’s announcement marks the second time that districts outside of Strike Force locations participated in a national takedown, and they accounted for 82 defendants charged in this takedown.

*********

For the Strike Force locations, in the Southern District of Florida, a total of 100 defendants were charged with offenses relating to their participation in various fraud schemes involving approximately $220 million in false billings for home health care, mental health services and pharmacy fraud.  In one case, nine defendants have been charged with operating six different Miami-area home health companies for the purpose of submitting false and fraudulent claims to Medicare, including for services that were not medically necessary and that were based on bribes and kickbacks.  In total, Medicare paid the six companies over $24 million as a result of the scheme.

In the Southern District of Texas, 24 individuals were charged in cases involving over $146 million in alleged fraud.  One of these defendants is a physician with the highest number of referrals for home health services in the Southern District of Texas.  This physician has been charged with participating in separate schemes to bill Medicare for medically unnecessary home health services that were often not provided.  Numerous companies that submitted claims to Medicare using the fraudulent home health referrals from the physician were paid over $38 million by Medicare.

In the Northern District of Texas, 11 people were charged in cases involving over $47 million in alleged fraud.  In one scheme, a physician allowed unlicensed individuals to perform physician services and then billed Medicare as if he performed them.  Additionally, the physician certified patients for home health care that was often medically unnecessary.  Home health companies submitted approximately $23.3 million in billings to Medicare based on the physician’s fraudulent certifications.

In the Central District of California, 22 defendants were charged for their roles in schemes to defraud Medicare of approximately $162 million.  In one case, a doctor was charged with causing almost $12 million in losses to Medicare through his own fraudulent billing, including performing medically unnecessary vein ablation procedures on Medicare beneficiaries.

In the Eastern District of Michigan, 19 defendants face charges for their alleged roles in fraud, kickback, money laundering and drug distribution schemes involving approximately $114 million in false claims for services that were medically unnecessary or never rendered.  Among these are owners of a physical therapy clinic who lured patients through the payment of cash kickbacks and medically unnecessary prescriptions for Schedule II medications for the purpose of stealing more than $36 million from Medicare.

In Tampa, Orlando and elsewhere in the Middle District of Florida, 15 individuals were charged with participating in a variety of schemes including compounding pharmacy fraud and intravenous prescription drug fraud involving $17 million in fraudulent billing.  In one case, the owner of several infusion clinics allegedly defrauded the Medicare program of over $8 million through a scheme involving reimbursement claims for expensive intravenous prescription drugs that were never purchased and never administered to patients.

In the Northern District of Illinois, six individuals were charged in cases related to three different schemes involving bribery and false and fraudulent claims for home health services and disability benefits.  The charged defendants include individuals who owned or co-owned the fraudulent providers and a medical doctor.  In total, these schemes resulted in over $12 million being paid to the defendants and their companies.

In the Eastern District of New York, 10 individuals were charged in six different cases, including five individuals who were charged for their roles in a scheme involving over $86 million in physical and occupational therapy claims to Medicare and Medicaid.  In that case, the defendants are alleged to have filled a network of Brooklyn clinics that they controlled with patients by paying bribes and kickbacks.  Once at the clinics, these patients were subjected to medically unnecessary therapy.  The defendants then laundered the proceeds of the fraud through over a dozen shell companies.

In the Eastern District of Louisiana, three defendants were charged in connection with a health care fraud and wire fraud conspiracy involving a defunct home health care provider.  This scheme centered on the payment of kickbacks through patient recruiters in exchange for patients who oftentimes never received nor qualified for home health care as billed.  Once admitted, patient medical records were routinely fabricated and altered to support false and fraudulent claims to Medicare.

*********

In addition to the Strike Force, today’s enforcement actions include cases brought by 26 U.S. Attorney’s Offices, including the unsealing of search warrants in investigations being conducted by the Eastern District of North Carolina, Southern District of Georgia, District of Columbia, Eastern District of Texas, Southern District of West Virginia, Middle District of Louisiana, District of Minnesota, and the Northern District of Alabama.

In the Northern District of Georgia, nine defendants were charged for their roles in two health care fraud schemes involving $7 million in fraudulent billings.  Eight defendants were charged in a scheme where bribes and kickbacks were allegedly paid to a state of Georgia official in exchange for falsifying applications and licensing requirements and recommending the approval of unqualified mental health providers.

In the Middle District of Alabama, two defendants were charged for their roles in a mental health services scheme allegedly involving $246,000 in fraudulent billings.

In the Middle District of Tennessee, a doctor was charged for his role in an illegal kickback scheme under which he allegedly referred patients to a certain DME supplier in exchange for cash kickbacks.

In the Western District of Kentucky, a business entity was charged for its role in a health care fraud scheme.

In the Southern District of Ohio, two defendants were charged for their roles in a $7.5 million home healthcare fraud scheme.

In the Western and Eastern Districts of Pennsylvania, three defendants were charged for their roles in drug diversion and embezzlement schemes.

In the Southern District of New York, a pharmacist was charged for his role in a scheme involving over $51 million in fraudulent Medicare and Medicaid billings.

In the Districts of Maine, Alaska, Kansas, Connecticut and Vermont, five defendants were charged for their roles in Medicaid-related schemes.

In the Eastern District of Missouri, four defendants, including a doctor and pharmacist, were charged for their roles in schemes involving over $3 million in billings.

In the Southern District of California, eight individuals were charged in health care-related cases.  In one case, five individuals, including a doctor and a pharmacist, were charged in a scheme to pay bribes and kickbacks to doctors in exchange for prescribing expensive durable medical equipment and compound pain creams that were not medically necessary.  The indictment alleges that approximately $27 million in false and fraudulent claims were submitted to insurers.

In the District of New Mexico, two defendants were charged for their roles in a Medicaid fraud scheme.

In the Northern District of Iowa, a settlement agreement was reached with a corporate entity for its role in a health care fraud scheme in a juvenile residential treatment facility.

In the District of Oregon, one defendant was charged for his role in a $1.7 million optometry services scheme.

In the District of Puerto Rico, civil demand letters were issued to six individuals for their roles in a scheme to defraud the Medicaid program.

In addition, in the states of Florida, Iowa, South Dakota, Indiana, New York, Michigan, Oklahoma, Rhode Island, Louisiana, Pennsylvania, New Hampshire, Oregon, Kentucky and Alaska, 49 defendants have been charged in criminal and civil actions with defrauding the Medicaid program and 57 sites were searched, pursuant to search warrants.  These cases were investigated by each state’s respective Medicaid Fraud Control Units.

The cases announced today are being prosecuted and investigated by U.S. Attorneys’ Offices nationwide, along with Medicare Fraud Strike Force teams from the Criminal Division’s Fraud Section and from the U.S. Attorney’s Offices of the Southern District of Florida, Eastern District of Michigan, Eastern District of New York, Southern District of Texas, Central District of California, Eastern District of Louisiana, Northern District of Texas, Northern District of Illinois and the Middle District of Florida; and agents from the FBI, HHS-OIG, Drug Enforcement Administration, DCIS and state Medicaid Fraud Control Units.

A complaint or indictment is merely a charge, and all defendants are presumed innocent unless and until proven guilty.

The court documents for each case will posted online, as they become available, here:https://www.justice.gov/opa/documents-and-resources-june-22-2016-medicare-fraud-strike-force-press-conference.

The Affordable Care Act has provided new tools and resources to fight fraud in federal health care programs.  The law provides an additional $350 million for health care fraud prevention and enforcement efforts, which has allowed the department to hire more prosecutors and the Strike Force to expand from two cities to nine.  The act also toughens sentencing for criminal activity, enhances provider and supplier screenings and enrollment requirements and encourages increased sharing of data across government.

In addition to providing new tools and resources to fight fraud, the Affordable Care Act clarified that for sentencing purposes, the loss is determined by the amount billed to Medicare and increased the sentencing guidelines for the billed amounts, which has provided a strong deterrent effect due to increased prison time, particularly in the most egregious cases.

Since January 2009, the Justice Department’s Civil Division, along with U.S. Attorney’s Offices around the country, has recovered a total of more than $29.9 billion through False Claims Act cases, with more than $18.3 billion of that amount recovered in cases involving fraud against federal health care programs.

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

On June 17, the IRS duly recognized that employers (and state workforce agencies) need more time to adjust to WOTC program changes initiated by the so-called “Protecting Americans from Tax Hikes Act of 2015.” With the issue of Notice 2016-40, employers have been given another three month to apply for potentially tens of thousands of dollars each in credits for hiring certain population groups. At about the same time, the Department of Labor also issued Training and Employment Guidance Letter Number 25-15, dealing with the same issues. [The author provides details about recent changes to WOTC forms and deadlines, and benefits to employers of the WOTC program are also noted.]

Background:
Back in March, the IRS issued Notice 2016-22, which temporarily modified the normal 28-day application deadline for WOTC applications. That notice established June 29 as the grand-deadline to submit applications for all employees hired from January 1, 2015 through May 31, 2016.

Built into that schedule, however, was anticipation that the Department of Labor would issue updated WOTC forms in a timely manner. Employers and state workforce agencies would need time to adjust their procedures and technology to handle all the changes.

Last week, however, we found ourselves just 12 days away from that original deadline, still waiting for the updated forms. Obviously, 12 days was not enough time for the State Workforce Agencies to make this work. We now collectively have been granted until September 28 to get our systems into working order and to submit all outstanding applications.

This deadline extension applies to employees hired January 1, 2015 through August 31, 2016. Other than extending the time frames of transition relief, the recent notice does not modify the terms of the original IRS Notice 2016-22.

As an additional benefit, companies that are new to the WOTC Program now have more time go back and submit all their new hires since 1/1/2015. Typically, a WOTC Tax Credit is $2400-$9600 per eligible employee.  Free application are availalble online at WOTCsoftware.com

©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com