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Home Health & Hospice Care Fraud Defense

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Home Health & Hospice Care Fraud Defense

Driven Attorneys for Defense of Home Health & Hospice Care Fraud Charges

In recent years, home health agencies (HHAs) and hospices have become primary targets in the federal government’s fight against Medicare fraud. HHAs and hospices around the country are facing audits and investigations with increasing frequency, and those that fail to effectively defend themselves are facing severe consequences – including civil monetary penalties (CMPs) and federal imprisonment.

As the owner or operator of a home health agency or hospice, you have enough on your plate without worrying about an invasive audit or investigation conducted by government contractors or federal agents. Unfortunately, due to a recent spate of cases involving large-scale Medicare fraud schemes by unscrupulous scam artists, HHAs and hospices are now at the center of the government’s fight against Medicare fraud. This means that legitimate providers who are focused on meeting their patients’ needs within the confines of the law are being targeted for Medicare enforcement, with auditors and investigators looking for any justification to seek recoupments and pursue civil or criminal charges.

With the ever-changing nature of the Medicare billing regulations, and with the complex web of health care laws governing home health agencies and hospices, audit contractors and federal agencies (including the Centers for Medicare and Medicaid Services (CMS), the Drug Enforcement Administration (DEA), the Federal Bureau of Investigation (FBI), and the Office of Inspector General (OIG)) have a deep bag of tools for taking action against these businesses. While intent to commit fraud is a requirement to prove criminal culpability,

(i) there are several factors that can make honest mistakes look like intentional fraudulent billings, and

(ii) even honest mistakes have the potential to lead to civil charges, which carry the potential for exorbitant financial liability as well as federal benefit program exclusion.

As a result, regardless of what you think about the merit of the government’s inquiry into your business, you need to take it very seriously, and this starts with engaging a highly-experienced legal team to deal with the auditors or investigators on your behalf.

Experienced Legal Representation for Home Health Agencies and Hospices Nationwide

The federal law health care fraud defense lawyers at Oberheiden, P.C., have decades of experience in home health and hospice care fraud investigations both as federal prosecutors and as attorneys for providers in the private sector. Our team of negotiators and litigators has successfully resolved CMS contractor audits and federal fraud investigations, often without our clients ever being charged (noting that every case is different and prior results do not guarantee the same result in your case). If you are facing an audit or investigation, avoiding charges needs to be your top priority, and our team of health care fraud defense lawyers can strategically defend your practice while you continue to focus your efforts on meeting your patients’ needs.

The leaders of our federal defense team held senior positions within the U.S. Department of Justice (DOJ) prior to entering private practice, and all of the attorneys on our federal health care fraud defense team have maintained significant careers focused on issues relating to Medicare and other benefit program fraud. As a result, we offer a strong combination of knowledge about CMS contractor audits and federal investigative procedures as well as a deep and nuanced understanding of the federal health care laws and regulations.

About Our Home Health and Hospice Care Fraud Practice

We represent home health agencies, hospices, their owners, executives, and key personnel in all matters pertaining to federal health care audits and investigations. Our attorneys routinely assist clients with matters including:

  • CMS Contractor Audits and Appeals – Under CMS’s “fee for service” audit program, private contractors get paid to target HHAs and hospices and find justification to seek recoupments, deny pending Medicare reimbursements, or both. These contractors, including Zone Program Integrity Contractors (ZPICs), Medicare Administrative Contractors (MACs), and Recovery Audit Contractors (RACs), have broad authority to conduct invasive audits, and they can also refer providers to the OIG or DOJ for federal prosecution.
  • Federal Agency Investigations – The attorneys on our health care fraud defense team have significant experience representing home health agencies, hospices, and other health care providers with investigations conducted by all major federal health care and law enforcement agencies. We understand the issues involved, the consequences that are at stake, and the strategic focus that is required to seek a favorable resolution.
  • Grand Jury Investigations – A grand jury investigation can be a precursor to an indictment on felony fraud charges. If your HHA or hospice is under investigation, or if anyone affiliated with your business has received a grand jury subpoena, it is imperative that you seek experienced legal representation right away.
  • Civil Health Care Fraud Enforcement – Many home health and hospice care investigations are civil in nature. This means that the government is seeking financial penalties including fines, treble (triple) damages, and recoupments, and your HHA or hospice may also be facing the possibility of federal health care benefit program exclusion. Our attorneys provide strategic and aggressive representation in civil cases, seeking to negotiate favorable resolutions that protect our clients’ businesses without the need to go to trial.
  • Criminal Health Care Fraud Prosecution – If you or your business is under threat of criminal prosecution, our attorneys will fight to defend your freedom and protect your right to serve your patients. Criminal penalties for health care fraud include large fines, federal imprisonment, and program exclusion – which is mandatory for many health care fraud-related convictions.

Home Health and Hospice Medicare Fraud FAQs

Q: Why is my home health agency or hospice being accused of Medicare fraud?

If your home health agency or hospice is being targeted by auditors or investigators, the first thing you need to know is this: you are not alone. Audit contractors have strong financial incentives to pursue as many providers as possible, and many federal agencies have mandates to crack down on Medicare fraud in the home health and hospice settings. As a result, HHAs and hospices around the country are facing federal inquiries like never before.

With this in mind, there are three primary reasons why your HHA or hospice may be under investigation:

  • A ZPIC, MAC, or RAC has decided to conduct an audit of your business;
  • The government’s data analytics tools have flagged your Medicare billings as showing possible signs of fraud; or,
  • Someone (such as a disgruntled former employee or a competitor) has filed a qui tam lawsuit with the OIG or DOJ.

Q: What are some of the most common examples of health care law violations committed by home health agencies and hospices?

Many HHA and hospice Medicare investigations focus on the requirement for a valid certification. Medicare’s billing regulations stipulate that a patient is only eligible for hospice care if a physician has certified that he or she has a life expectancy of six months or less. Similarly, a patient is eligible for home health services reimbursement through Medicare only if he or she has been certified as homebound. Failure to obtain certifications, relying on fraudulent certifications, forging and falsifying certifications, and failing to discharge patients after their conditions improve are all violations that can lead to civil or criminal charges.

In addition to certification-related issues, other common allegations in home health and hospice care fraud investigations include:

  • Failing to obtain valid and signed “election statements” from patients prior to commencing care;
  • Ordering medications to treat patients’ underlying medical conditions (as opposed to medications that are solely for pain relief);
  • Ordering unnecessary or redundant medical equipment (including beds, wheelchairs, and walkers); and,
  • Medicare billing violations, including billing for services or medications that were not provided, upcoding, unbundling, double-billing, and preparing improper cost reports.

Q: What are some examples of common mistakes that can trigger allegations of Medicare fraud for home health agencies and hospices?

In many cases, honest mistakes are to blame for home health agencies’ and hospices’ improper Medicare billings. These mistakes often result from issues such as lack of employee training, relying on outdated or inadequate compliance programs, and simple human error. Some of the most common mistakes that can raise red flags for auditors and investigators include:

  • administrative errors with regard to patient records and Medicare billings;
  • relying on outdated Medicare billing regulations; and,
  • unknowingly relying on invalid or fraudulent physician certifications.

If your HHA or hospice has committed billing errors that need to be addressed, one of the key elements of our defense strategy will be to demonstrate that the errors were unintentional and that you are taking proactive measures to ensure that similar mistakes will not happen in the future.

Q: What are the rules regarding referral fees and kickbacks for home health agencies and hospices?

Home health agencies and hospices are subject to the same restrictions regarding referral fees and kickbacks as other providers who bill Medicare for patients’ services, medication, equipment, and supplies. Laws including the Anti-Kickback Statute and the False Claims Act make it illegal for any health care provider to bill Medicare for amounts that are paid as compensation or other remuneration for referring patients or recommending certain medications or other products.

Q: Where can I learn more about the federal government’s efforts to target home health agencies and hospices?

If you or your business is being targeted in an audit or investigation, we encourage you to contact us promptly for a free and confidential case assessment. You will have the opportunity to personally meet with our health care fraud defense lawyers and obtain detailed legal advice tailored to your unique circumstances. For more general information about defending against Medicare audits and health care fraud investigations, we encourage you to read:

Trusted Advocates and Representatives for Health Care Providers Facing Federal Audits and Investigations

Led by partner Dr. Nick Oberheiden, Oberheiden, P.C.’s health care fraud defense team is an experienced source of advice and representation for health care providers across the United States.  If you are facing an audit or investigation, you need legal representation, and you need a team of attorneys who have the skills, experience, and connections necessary to effectively limit the scope of your case and efficiently mount a strategic defense. At Oberheiden, P.C., we offer:

  • Advantage Through Experience – Our attorneys offer the insights that can only be gained from personally handling hundreds of criminal trials and multiple hundreds of federal investigations.
  • Victories in 21 States & Counting – With a practice providing federal health care law defense, we have successfully represented clients in 21 states across the country.
  • 24/7 Availability – We are available when you need us. We understand that you do not have time to waste, and we are prepared to start representing you immediately.

Accused of Home Health Care or Hospice Fraud? Schedule Your Free Consultation at Oberheiden, P.C.

If you are interested in engaging the health care fraud defense team at Oberheiden, P.C., for your home health agency’s or hospice’s legal defense, we encourage you to contact us to arrange a free case assessment. You can contact us 24/7, and if we are not available immediately a member of our team will respond to your inquiry as soon as possible. You can reach us nationwide at (888) 452-2503, or submit your case online now.

Orange County 714-294-2000
Los Angeles 310-873-8140
Detroit 313-888-8807
Nationwide 888-452-2503