By Tim Rowan, Editor & Publisher, Home Care Technology Report

On June 23, Judge Michael L. Rankin of the Superior Court of the District of Columbia, Civil Division, declared null and void the October, 2015 dismissal of Joanne Cunningham and Laurie Neander from the National Association for Home Care Board of Directors. The lawsuit was brought in January against NAHC, its president Val Halamandaris, its board chair Denise Schrader, and its attorney Hugh K. Webster by the Home Care Association of New York on behalf of Cunningham, its president. Ms. Neander is the Executive Director of At Home Care in Oneonta, New York. She is an HCA member and former board member. [Details are provided in tis article about the background of this case, activities undertaken by the NAHC and Home Care Association of New York (HCANY) during 2015-2016,  and Judge Rankin’s ruling against NAHC.  Longer-term consequences of this ruling  are expected to affect home healthcare organizations’  needed compliance with their organizations’ own bylaws.]

 

Background
On October 23, 2015, Attorney Hugh Webster delivered letters on behalf of NAHC informing Cunningham and Neander that they had engaged in activities that disqualified them from remaining on the NAHC board. This in spite of a NAHC by-law, Judge Rankin noted, that requires such dismissals to occur during a board meeting with the member in question present. Cunningham had been elected to the board by her peers in the Forum of State Associations, a NAHC affiliate organization made up of state executive directors. Her two-year term was set to expire four days after she received the Webster letter. (See HCTR, October 29, 2015 and December 2, 2015)

In addition to violating this NAHC by-law, Webster’s letters also crossed a line by grounding his argument in the fact that both board members headed organizations that had become members of the Visiting Nurse Associations of America, which NAHC regards as a rival association. This accusation ignored another NAHC by-law, which bars board members only from serving on a rival agency’s board, not from holding a membership in other national home care organizations.

On June 11 of this year, long after the HCA-NY lawsuit was filed and initial court hearings had been conducted, NAHC took a second formal action to reaffirm its dismissal of the two board members. Judge Rankin’s decision voided both the October letters and NAHC’s June, 2016 action. The HCA suit did not seek monetary damages other than that NAHC pay its legal fees, which the judge did agree to and which are still being calculated.

Next steps
On July 13, a status hearing was held before Judge Rankin so that NAHC attorneys could produce evidence that their client had obeyed his June 23 instructions, which included a demand that the NAHC board pass a formal resolution declaring that Cunningham and Neander had never been dismissed, that they had continuously been and were still members in good standing of the NAHC board. We are awaiting publication of the results of that hearing.

Shortly after the judge’s June 23 reinstatement, Joanne Cunningham and Laurie Neander resigned as NAHC board members. According to the explanation in the HCA newsletter:

Both Ms. Cunningham and Ms. Neander resigned from the NAHC Board of Directors on July 6, 2016. They both resigned because it became apparent during the course of the lawsuit that, although certain members of the NAHC Board and management remain dedicated to furthering the interests of NAHC, other members of the NAHC Board and management appeared focused on advancing their personal interests ahead of NAHC’s interests. Ms. Cunningham and Ms. Neander could no longer work and fulfill their Board duties in that type of environment.

Long term consequences
Will this court case end here or will it have a broader impact beyond home care? It does set a precedent that may well be cited in future cases. Associations have been put on notice that they must comply with their own bylaws as they would comply with a contract. Attorneys have been alerted that they may not aid and abet an association that schemes to violate its own by-laws. With the decision being rendered in a DC Superior Court and so many national associations based in Washington, this may be a case that reaches beyond the parties involved, beyond home care, even beyond healthcare.

For reference, we reprint HCA’s letter updating its members elsewhere in this week’s issue.

©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

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From the July 15 edition of ASAP, a weekly publication of the Home Care Association of New York State:

In January 2016, HCA commenced litigation against the National Association for Home Care and Hospice (NAHC), NAHC’s Board Chair, its President and CEO, and outside legal counsel, for violating the NAHC bylaws when they illegally attempted in October 2015 to remove HCA’s representatives – HCA President Joanne Cunningham and HCA Member (and HCA Board Member) Laurie Neander – from the NAHC Board of Directors.

HCA just prevailed overwhelmingly in the lawsuit. In a June 23, 2016 order (available at http://hca-nys.org/wp-content/uploads/2016/07/ HCANAHCorderofjudgment.pdf ), the Superior Court of the District of Columbia ruled in HCA’s favor, declaring that: the October 2015 action (as well as a subsequent June 2016 Board action) of the Defendants violated NAHC’s bylaws and were invalid; both Ms. Cunningham and Ms. Neander were never removed from the Board; and Ms. Cunningham and Ms. Neander continued to serve as Board members of NAHC with uninterrupted service following Defendants’ invalid actions.  [More details about Neander’s and Cunningham’s  subsequent activities with NAHC  activities and duties are provided in this short article.]

 

The Superior Court also ordered NAHC to pay HCA’s legal fees. The Superior Court will be reviewing HCA’s invoices for legal fees and determine the exact amount NAHC must pay HCA.

Both Ms. Cunningham and Ms. Neander resigned from the NAHC Board of Directors on July 6, 2016. They both resigned because it became apparent during the course of the lawsuit that, although certain members of the NAHC Board and management remain dedicated to furthering the interests of NAHC, other members of the NAHC Board and management appeared focused on advancing their personal interests ahead of NAHC’s interests. Ms. Cunningham and Ms. Neander could no longer work and fulfill their Board duties in that type of environment.

HCA has been reasonable in its approach throughout. It made numerous attempts to informally resolve its concerns with NAHC before it commenced the lawsuit, but NAHC had refused to engage or respond to HCA’s outreach. This forced HCA to commence the lawsuit and seek its relief through the Superior Court. The Superior Court’s order did not address HCA’s count in the lawsuit concerning wrongful interference with business relations. That count is still pending. HCA will continue to pursue relief on that count.

This article originally appeared in ASAP, the newsletter of the Home Care Association of New York State. Reprinted by permission.

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Portsmouth, NH, July 26, 2016– – ChartaCloud Technologies LLC today announced its agreement with OPERACARE Inc. (San Antonio, NM) to introduce and offer its CMS OASIS claims, pre-submission claims and proactive OASIS analytics software and services. OPERACARE will be offered via ChartaCloud’s ChartaCares health care services business. OPERACARE’s design and development was led by an experienced CMS/State OASIS Coordinator skilled in claims data monitoring and OASIS Analytics as utilized by CMS/MAC auditors to oversee payment claims validity and fraud detection programs.

The software and supporting review service enables home health care providers to have their CMS claims reviewed by a third party, submit accurate health care episode documentation, manage re-certifications and provide accurate pre-claim submissions in an era of increasingly aggressive CMS/Auditing protocols. In addition, OPERACARE provides the basis for identifying opportunities for enhanced billing and providing outcomes data monitoring used to enhance HHA growth and financial stability in the new era of ‘value based purchasing/payments’ for HHA services. [More details about the increased need for healthcare at hoke and other healthcare sites engaging third party  reviews/audits of claim submissions are provided in this article.]

 

“Health care providers and their compliance officers are quite aware of the increasingly aggressive nature CMS’ MAC (Medicare Administrative Contractor) and RAP (Resource Allocation Plan) audits. Skilled home care service providers are being increasingly subjected to audits driven by claim inaccuracies, whether being done purposefully, inadvertently or inaccurately. While avoiding an audit is the first priority, profitably surviving in an industry under intense consolidation is a strategic imperative. Bottom line to both challenges is that claims have to be accurate, prepared in a timely manner and correctly coded,” said Michael McGowan, ceo, OPERACARE.

“With CMS’s increased MAC attention on expanding HHA audits and the pushing of MACs to be more aggressive, hundreds of preventable desk review risks are in play. Our policy which has been built into our system and service, is straight forward, don’t submit what you can’t defend. If we detect a concern we will call the provider,” he concluded.

“We are of course very excited about the expertise and the power found in OPERACARE to not only help our HHA customers submit accurately prepared claims but also with OPERACARE’s ability to help transform the business models of health care service providers to what is needed to survive, achieve financial stability and to grow new business. Having a system that enables resource allocation plan (RAP) submissions within 2-4 hours of a start/statement of care (SOC) visit and transitioning to a value based purchasing model to grow their businesses were very significant elements in our choice to offer OPERACARE,” said Rob Schimmel, COO, ChartaCloud. “In the end and as in any business, performance matters. And, we believe OPERACARE delivers significant performance benefits to HHAs,” he added.

More on the working relationship between OPERACARE and ChartaCloud can be found at: chartacloud.com/#!operacare-1/ax332

About ChartaCloud
ChartaCloud Technologies offers an end-to-end, full service approach to help business and educational institutions select, implement, and excel at the adoption of digital solutions proven to deliver organizational efficiency and profitability. Specializing in field services, education and healthcare, we help our customers to define and deploy solutions to become leaders in their industry and achieve their stated goals and vision. Our core technologies are designed to help our customers secure a competitive advantage in the era of digital transaction management, mobility, and humanoid robotics.
chartacloud.com

About ChartaCares
With a focus on advancing ongoing HIPAA compliance and quality of care, ChartaCares provides ACOs, hospitals, VNAs and home care service providers, skilled nursing facilities, emergency clinics, and specialty medical practices, physical therapists, behavioral health centers, and dentists foundational secure health IT systems, robotic assistive medical care, and advanced health care predictive analytics to reduce hospital re-admissions and manage preventable admissions.
chartacares.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

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By Tim Rowan, Editor & Publisher of Home Care Technology 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

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By Tim Rowan, Editor & Publisher of Home Care Technology Report

 

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.”

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By Tim Rowan. comp., editor & publisher of Home Care Technology Report

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.”

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:

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

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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.]

 

Loretta Lynch

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.

Sylvia Burwell

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.

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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.

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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

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Schaumburg, IL and Clearwater, FL — Procura Healthcare Software today announced that it has entered into a definitive agreement to acquire Suncoast Solutions, the hospice technology arm of Empath Health. Vancouver, BC-based Procura released a statement asserting that, “This transaction joins two of the strongest performing companies in the healthcare industry and deepens Procura’s commitment to the industry’s hospice segment, which has rapidly grown to over $20 billion annually.”

Procura provides enterprise software to home health agencies, community care agencies, and hospice and residential care agencies in the U.S., Canada, and Australia. Empath Health is a nonprofit integrated network of care. Empath’s technology arm, Suncoast Solutions, provides software that supports management of clinical and financial hospice processes and related programs. [More details about the terms of Procura Healthcare Software’s agreement  with Suncoast Solutions and Empath Health are provided in this article.]

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Schaumburg, IL — June 24, 2016 — Procura, with its reach into Canada, the U.S, and Australia the world’s largest provider of business management software to the home and community healthcare industry, announced last week a record year of growth and expansion as the company’s fiscal year concluded on March 31, 2016.  During the previous 12 months, Procura:

  • Added more than 100 new customers across its product portfolio of Procura, ContinuLink, Igea and Progresa software;
  • Posted a 38% growth in revenues across its SaaS portfolio;
  • Opened a new Global Executive Center of Excellence in Schaumburg IL, representing the company’s global management headquarters going forward;
  • Expanded innovation and product development spending by millions of dollars;
  • Completed the integration of the Igea product and team into the company’s operations – an acquisition that was closed at the end of the previous fiscal year;
  • Expanded its executive leadership team to include four new executives in customer success, marketing, sales and product development;
  • Launched numerous product enhancements and innovations. [Details are provided in this article summarizing Procura executives views on business’s growth in 2016 and predictions for same in 2017.Four new executives and their roles at Procura are introduced.]

 

Chris Junker

Christopher Junker, Procura’s CEO, commented, “I am really proud of our team and all we have accomplished in the past fiscal year.  To add more than 100 new customers and grow our SaaS revenue by 38% is a phenomenal achievement. We are seeking to completely reinvent this company from top to bottom, reworking every business process, all of our products, and our team structures to ensure we’re positioned to continue to lead the marketplace in home health software.”

John Walles, Procura’s CFO, added, “Our efforts to change how we do business across the board are delivering dividends – it’s been a lot of work and there’s much more we have to do in this fiscal year to continue to expand the growth of this company. But we’re really pleased with what we’ve accomplished so far and how it has made every part of our business stronger.”

“In the coming year, our Fiscal 2017,’ you’ll see even more changes,” Junker continued. “We will be moving into a large additional space in Schaumburg, IL, which will be our Central US innovation and client support center, augmenting the teams we have around the world in those functions with additional resources. Our product teams have exciting new projects in the works to roll out over the next year. Additionally we are looking externally for growth opportunities that can help us expand even more rapidly. It will be an exciting business year.”

New key execs introduced
During FY16, Procura added four experienced executives to its staff:

  • Ralph Schiavone, VP, Product Development: responsible for product development planning, roadmapping and development. He most recently served as Director of Solutions Development for Allscripts.
  • Debbie Cullen, Global Vice President, Customer Success: responsible for global customer relationships. She joined Procura by walking across the street from her previous job as Vice President of Global Customer Services and Support for CellTrak.
  • Stewart Campbell, Vice President, Global Marketing: heads up all domestic and global marketing activities. He joined Procura from Microsystems, a Chicago-based provider of document management software.

As this issue was going to press, Procura also announced on June 28 the addition of Jennifer Gosizk to its executive leadership team as Senior Vice President, Sales. Jennifer joins Procura from SAP where she was most recently Vice President, Cloud HCM Healthcare Sales. Jennifer will be located at the company’s global headquarters in Schaumburg, Illinois.

Gosizk brings to Procura more than 15 years of enterprise experience in the healthcare field with previous positions at Oracle, Taleo, Resource Technology Associates and others in addition to SAP. Junker commented on her addition to the executive team: “We’re thrilled to add such a high caliber talent with a proven track record to lead our sales organization. Jen brings with her more than 20 years of sales leadership experience and 15 years leading teams in the healthcare, hospital and home care markets.  She is exactly what we need as we continue in this period of aggressive growth and market expansion.”

 Gosizk will be responsible for revenue growth across all software products, ContinuLink, Procura, Igea and Progresa. About all four new executives, Junker added, “We have sought to build our executive team around strong leaders with broad healthcare and software industry backgrounds. These four individuals join an already strong team of executive leaders in helping drive future growth. We are very pleased with the synergy in our leadership team.”

 

©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

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 by Merrilly Evdokimoff, RN, PhD

The dual approach of the use of a patient/family facing electronic personal health record and support from a certified lay patient navigator has demonstrated an improvement in Patient Activation measures in home health care patients, according to Gail Embt, CEO of Kinergy Health (McLean VA). Lay navigators with certified home care agencies and hospital discharge departments have demonstrated improved patient outcomes in patient satisfaction, improved medication adherence, lower ER usage and lower rehospitalization rates. [Details are provided about a recent pilot project of lay health navigators’ interventions  with healthcare at home patients conducted by Kinergy Health that demonstrated decreased patients’ hospitalizations and other favorable findings.]

In a recent pilot project Kinergy Health conducted at a certified home health agency, the use of this high tech, high touch approach demonstrated increased Patient Activation scores, resulting in improved self-management and fewer rehospitalizations as well as improved patient satisfaction.

Use of navigators has been demonstrated to:

*Decrease rehospitalizations (betterhealthpartnership.org/pdfs/lc_presentations/2015_10/lc_xvii_patient_navigators_100915.pdf)

  • Decrease cancelled and missed appointments
  • Improve patient/family satisfaction
 
Disease specific interventions with significant findings with Navigators include:
 Improve control of heart failure management (cdc.gov/pcd/issues/2011/nov/10_0282.htm)

Use of a health navigator in the home health care setting has demonstrated:

 Improved patient satisfaction scores
  • Early identification of change in status or unresolved issues
  • Allowance of clinical staff to focus on clinical issues, while navigators assist with “social determinants” of health.
  • Improve patient self-management through increased patient activation.
  • Ease of communication with family and other care providers.
  • Maintain connection with Agency after discharge.
  • In conjunction with use of community health workers.
  • Agency being proactive and standing out to referral sources.
 As other health care settings such as hospital discharge departments and physician’s offices have begun to implement the use of navigators, it is time for the home care industry to assess the usefulness in the home health setting.
  
Merrily Evdokimoff, RN,PhD has over 30 years experience in home health, and currently teaches Community Health Nursing at University of Massachusetts-Boston and is a consultant to home care agencies and vendors. She is a nationally recognized speaker on clinician education and patient engagement. She may be reached at merrilyevd@gmail.com or 508-560-3801.

©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

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