HHA Providers in High Risk Areas Feel the HEAT

Recently, 14 individuals were arrested or indicted for violations of the Anti-Kickback Statute and for health care fraud and abuse associated with home health agencies (HHAs) in the Detroit and Miami metropolitan areas.  These two areas have been identified by CMS as having a high potential for fraud and abuse amongst HHA providers.  All of the indictments or arrests were made in conjunction with Medicare Strike Forces operating in those cities under the Health Care Fraud Prevention and Enforcement Action Team known as HEAT.

Detroit.  A physician and three others were indicted of conspiring to defraud health care programs of $7 million, according to the Department of Justice.  Dr. Kutub Mesiwala was accused in the indictment of  receiving kick-backs for referring patients to Advance Home Health and for falsely certifying their need for home health care.  The other three allegedly paid kick-backs to Medicare beneficiaries for their signatures on blank physical therapy records which were later filled in with false medical records and used by Advance Home Health and Perfect Home Health.

A co-owner of Empirical Home Health Care was indicted for paying kick-backs to individuals, including physicians, who were recruited to be patients for the HHA.   The indictment charges that these referrals resulted in $2.6 million in Medicare payments, according to the Department of Justice.  Two other people were indicted for violations of the Anti-Kickback Statute for recruiting Medicare beneficiaries for Prestige Home Health and Royal Home Health.

Miami.  The owner of Acclaim Home Health was arrested for conspiracy to commit health care fraud. Orelvis Olivera was accused of paying kick-backs to patient recruiters for Acclaim Home Health.  In addition Mr. Olivera allegedly solicited and received kick-backs from other Miami based home health agencies for referring Medicare beneficiaries to those agencies.  Acclaim billed Medicare for $8 million in association with beneficiaries who were recruited.

Six individual were indicted for soliciting and receiving kick-backs for recruiting patients for Professional Medical Home Health in South Florida.  In addition medical records were falsified to support fraudulent billing for services that were either medically unnecessary or that were not provided. These activities allegedly resulted in $6.2 million in Medicare claims, according to the Department of Justice.

HEAT.  All of these arrest or indictments were the result of Medicare Strike Forces operating under HEAT.  Since their inception Medicare Strike Forces have been responsible for the indictment of 2,000 individuals who have collectively billed Medicare for more than $6 billion.  Medicare Strike Forces are comprised of HHS, Department of Justice, and local investigators who work together to identify and prosecute fraud against Medicare.  Medicare Strike Forces are operating in Brooklyn, Los Angeles, Chicago, Miami and Dade County, Dallas, Detroit, Tampa, Houston, and Baton Rouge.

Moratoria.  All of the indictments and arrests occurred in areas where CMS has established a moratorium on the enrollment of new HHAs.  The Patient Protection and Affordable Care Act (ACA)(P.L. 111-148) gave CMS the ability to place a temporary  moratoria on the enrollment of new providers and suppliers in areas where there is a high risk of fraud, waste or abuse.  A moratorium on the enrollment of new HHAs was first established for Miami and Dade County Florida on July 31, 2013 and for Detroit and Wayne County Michigan on February 4, 2014.    These moratoria have been extended through December 31, 2014.

CMS choose to place a moratorium on new HHA enrollments in these areas based on review of law enforcement data and its own enrollment and billing data.  The areas selected for the moratorium were first identified by a high rate of fraudulent activity.  Then the number of providers per-capita and areas with higher than average per beneficiary expenditures were selected.  The results of the activities of the Medicare Strike Force teams in Detroit and Miami seem to support those findings.