Posted by: Robert Markette
August 22, 2007
Topic: Fraud and Abuse, Self Referral, False Claims

On Monday, the Department of Health and Human Services and the Department of Justice announced another test project designed to prevent fraudulent providers from operating in the Medicare system. This time the government is targeting fraudulent infusion therapy providers operating in South Florida.

As described by the press release, the new demonstration project will operate in a manner similar to the home health fraud enforcement project announced for Houston and L.A. Infusion providers in designated south Florida counties will be required immediately resubmit applications for enrollment. Failure to reapply within thirty days of receiving a notice to reapply will result in having your billing privileges revoked.

If an infusion therapy provider is discovered to have owners, partners, directors, or managing employees who have a felony conviction, the provider will have its privileges revoked. If the provider failed to report a change of ownership, it will have its billing privileges revoked. If a provider no longer meets each and every provider enrollment requirement, they will have their privileges revoked.

The providers that successfully reapply may find themselves subject to greater review, including site visits, depending upon the governments determination of the potential risk for more fraud. For many providers, this is a potentially onerous outcome. The announcement does not make it clear what factors will become part of the risk assessment. More audits and site visits will translate into more work for providers.

The press release went on to detail the successes of the South Florida Medicare fraud strike force. This effort uses real time access to Medicare billing records to assist the governments efforts to identify and prosecute Medicare fraud. It has resulted in a large number of indictments and convictions over the last eighteen months.

As with all other demonstration projects, I would expect this project to spread and to become a standard operating practice for the government. Given the success of the strike force in south Florida, I would not be surprised to discover similar efforts initiated in other parts of the country as well.

Over the last few months, the government has announced a number of efforts to combat fraud in the home health and related industries. Providers should be aware of these efforts, because they could very quickly become standard enforcement techniques. Although many of these efforts are aimed at over fraud, it is still drawing enforcement attention back to home health.

The government has not taken a hard look at fraud in the home health and hospice industries in a number of years. This has led many providers to become lax in their fraud and abuse compliance efforts. It seems that they are beginning to look again. Providers need to be aware that this is coming and prepare for it. Those providers who are engaged in questionable activities simply because others are doing the same, may be very surprised to find they are being prosecuted when the government starts to pursue fraud and abuse prosecutions in the home health and hospice industries more vigorously.

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