Kusserow on Compliance: CMS extends and expands enrollment moratoria in six states

CMS announced that it is extending for six months its temporary provider enrollment moratoria efforts in six states, as means to control fraud.  The agency is also expanding statewide the temporary provider enrollment moratoria on new Medicare Part B non‑emergency ground ambulance suppliers in New Jersey, Pennsylvania, and Texas and home health agencies (HHAs) in Florida, Texas, Illinois, and Michigan.  This statewide expansion also applies to Medicaid and Children’s Health Insurance Program (CHIP).  CMS also announced the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD), which gives CMS the ability to allow for provider and supplier enrollment exceptions in the moratoria areas if accesses to care issues are identified and for the development and improvement of methods of investigating and prosecuting fraud in Medicare, Medicaid, and CHIP.  The agency will also immediately lift the current temporary moratoria on all Medicare Part B, Medicaid and CHIP emergency ground ambulance suppliers.  The purpose of these actions is to focus on identifying parties engaged in fraudulent practices and to find means to better control the programs against such actions.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2016 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG reports investigative results for first half of 2015

The Office of Inspector General (OIG) mission is to provide independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS. It investigates allegations of fraud, waste, and abuse in all of the Department’s programs and is mandated to report to Congress semi-annually on the progress of meeting these mission goals. On June 1, 2015, the OIG released its first half of fiscal year (FY) 2015’s report, which included the following statistical results from investigations:

• Expected recoveries of over $1.8 billion ($544.7 million in audit receivables and $1.26 billion in investigative receivables that includes $142 million in areas such as the states’ shares of Medicaid restitution);
• 486 criminal actions against individuals/entities engaged in crimes against HHS programs;
• 326 civil actions, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters;
• 1,735 individuals and entities excluded from participation in federal health care programs.

The largest body of work in the report involved the investigation of matters related to the Medicare and Medicaid programs, such as: (1) patient harm; (2) billing for services not rendered, medically unnecessary services, or services more extensive than those actually provided; (3) illegal billing, sale, diversion, and off-label marketing of prescription drugs; and (4) solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies. The OIG also investigated cases involving organized criminal activity, medical identity theft, and fraudulent medical schemes that are established for the sole purpose of stealing Medicare dollars. Those who participate in these schemes may face heavy fines, jail time, and exclusion from participating in federal health care programs. The OIG took special note to highlight common criminal fraud scheme case types that occurred in the following areas:

• controlled and non-controlled prescription drugs;
• home health agencies and personal care services;
• ambulance transportation;
• durable medical equipment (DME); and
• diagnostic radiology and laboratory testing.

It also cited the results from the Health Care Fraud Prevention and Enforcement Action Team (HEAT) started in 2009 by HHS and the Department of Justice (DOJ) to strengthen programs and invest in new resources and technologies to prevent and combat health care fraud, waste, and abuse. HEAT continued to identify those who seek to defraud Medicare and Medicaid. The Medicare Fraud Strike Force, which operates in nine major cities and is a key component of HEAT, coordinates law enforcement operations conducted jointly by federal, state, and local law enforcement entities that prosecute health care fraud. During the first half of FY 2015, the efforts of this team resulted in the filing of charges against 69 individuals or entities, 124 criminal actions, and $163 million in investigative receivables. As part of the endeavors, the team refers credible allegations of fraud to CMS so that it can suspend payments to the suspected perpetrators, thereby immediately preventing losses from claims by Strike Force targets.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

 

Kusserow on Compliance: OIG reports on background checking by home health agencies

In response to a congressional request, the HHS Office of Inspector General (OIG) conducted a review to analyze the extent to which Home Health Agencies (HHAs) employed individuals with criminal convictions and to explore whether these convictions should have—according to State requirements—disqualified them from HHA employment. HHAs provide care—usually unsupervised—to patients in their homes and ensuring that their employees undergo a minimum level of screening would help protect the safety of Medicare beneficiaries. Home health programs have been a high priority for Medicare; Medicaid is intended to provide an alternative to institutional care for people with severe disabilities and it is intended that the needed services be delivered in a beneficiary’s home. This industry sector accounts for more than $20 billion paid by Medicare on behalf of 3.4 million beneficiaries with another estimated $15 billion in outlays paid by Medicaid programs.

This is a sensitive issue area as no one wants someone with a violent criminal history or one of committing thefts to be sent to care for beneficiaries in their home. To underscore, government concern with HHAs, including those concerns expressed by the Department of Justice (DOJ) and OIG, have found considerable evidence to recognize that home health is among the most vulnerable healthcare programs to fraud and abuse. The Government Accountability Office (GAO) recently reported 40 percent of all fraud convictions initiated by a group of Medicaid fraud-control units were for home health. CMS has been active in curbing problems in this arena by making uses of authority under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) to use temporary enrollment moratoria on home health providers in geographic areas of disproportionate crimes.

In their new report, the OIG noted that there are no federal laws or regulations that require HHAs to conduct background checks prior to hiring individuals or to periodically conduct background checks after individuals have been hired. State requirements for background checks vary as to what sources of information must be checked, which job positions require background checks, and what types of convictions prohibit employment. Though not stated in the report, what should be noted is that the background sanction-screening against the OIG’s List of Excluded Individuals/Entities (LEIE) is necessary and mandated in most states, along with screening State Medicaid sanction databases. However the problem is that most local criminal convictions are not related to violations of Medicare and Medicaid laws or regulation; and therefore not included in state reporting to the OIG LEIE.

In conducting the review, the OIG obtained a sample of Medicare-certified HHAs regarding all individuals they employed. It compared employee data with criminal history records to identify individuals with criminal convictions who were employed by the sampled HHAs. It also selected six employees for an in-depth review who had convictions for crimes against persons in the last five years and/or were registered sex offenders. Finally, it evaluated whether compliance with state laws would have led to disqualification of these six employees.

Findings

  • All HHAs conducted background checks of varying types on prospective employees.
  • Approximately half also conducted periodic checks after the date of hire.
  • Four percent of HHA employees had at least one criminal conviction that may or may not have disqualified them from employment.
  • Criminal history records reviewed were not detailed enough to enable a definitive determination of whether employees with criminal convictions should have been disqualified from HHA employment.
  • In-depth review of the six employees found that three had convictions for crimes against persons that would disqualify them from employment in HHAs, with the remaining three with convictions did not disqualify them from employment in their respective states.

Recommendation

CMS should promote minimum standards in background check procedures for HHA employee background checks by encouraging more states to participate in the National Background Check Program. CMS concurred with this recommendation.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2015 Strategic Management Services, LLC. Published with permission.

 

Kusserow on Compliance: Enrollment moratoria for new ambulance suppliers and home health agencies in several states

Over the last two years, I have been reporting on a large number of enforcement actions by the Department of Justice (DOJ) led Medicare Strike Force in eight target cities relating to cases involved home health agencies and ambulance services that many consider to be among the most vulnerable to fraud in health care. The OIG has issued a number of reports related to this problem. Going back to July 2013, CMS made their initial use of authority under the Patient Protection and Affordable Care Act (P.L. 111-148) to use temporary enrollment moratoria to prevent fraud where they have found that certain trends warranted such a moratorium on home health providers and ambulance suppliers in these geographic areas. Once again, they have issued a notice extending the temporary moratoria on the enrollment of new ambulance suppliers and home health agencies (HHAs) in specific locations within metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey. CMS also placed temporary moratoria on the enrollment of ground ambulance suppliers in Harris County, Texas and other surrounding counties and in Philadelphia, Pennsylvania and surrounding counties. CMS had previously extended all of the above-mentioned moratoria through February 2, 2015. The programs affected by the CMS decision is especially vulnerable to fraud are those that allow the Medicaid recipient to control the selection and payment of personal care attendants.

In determining to extend the moratoria again, CMS considered factors suggesting a high risk of fraud, waste, or abuse by relying on law enforcement’s experience with fraud trends and activities through investigations and prosecutions. CMS then confirmed a high risk of fraud, waste, or abuse in these provider and supplier types through data analysis. The resulting extended moratoria lasts for a period of six months.