FutureFocus April 18, 2018 CMS Expands Benefits For Medicare Advantage: Impact To PAC Providers

Lisa Remington

In this week’s FutureFocus, we provide insights about Medicare Advantage Plans and the recent announcement of expanding primary health-related benefits. Attorney, Elizabeth Hogue, warns providers to be cognizant of the experience levels of private duty companies working with the government or commercial insurers. In our Washington Report, we call attention to the Annual Anti-Fraud Report and the findings about home health providers. We remind providers that the low volume appeals settlements deadline have been extended.

Lisa Remington, President, Remington Health Strategy Group

In FY 2017, the government’s healthcare fraud prevention and enforcement efforts recovered $2.6 billion from individuals and entities attempting to defraud the federal government and Medicare and Medicaid beneficiaries, according to the fiscal year (FY) 2017 Health Care Fraud and Abuse Control Program report.

The departments of Justice (DOJ) and Health and Human Services (HHS), through the Health Care Fraud Prevention and Enforcement Action Team (HEAT) effort, use data analytics and surveillance to crack down on, prevent, and prosecute healthcare fraud.

With teams comprised of law enforcement agents, prosecutors, attorneys, auditors, evaluators and other staff, last year DOJ opened 967 new criminal healthcare fraud investigations of which federal prosecutors filed criminal charges in 439 cases involving 720 defendants. A total of 639 defendants were convicted of healthcare fraud related crimes.

Beyond criminal prosecution, the HHS Office of Inspector General excludes providers and suppliers who committed fraud or engaged in the abuse or neglect of patients in federal health programs. A total of 3,244 individuals and entities were excluded in FY 2017. Others were excluded as a result of licensure revocations. HHS can also suspend Medicare payments to providers during investigations of credible allegations of fraud, of which during FY 2017 there were 551 suspensions.

Some of these fraudulent practices include:

  • Home Health providers billing Medicare for home health services that were not medically necessary or were not provided, based upon false certifications of medical necessity; or, paying kickbacks to physicians to certify patients for medically unnecessary home health and personal attendant services. 
  • Providers operating “pill mills” out of their medical offices.
  • Clinics submitting false claims to Medicare and Medicaid for physical and occupational therapy.
  • Drug companies paying kickbacks to providers to prescribe their drugs, and pharmacies soliciting and receiving kickbacks from pharmaceutical companies for promoting their drugs.
  • Companies misrepresenting capabilities of their electronic health record software to customers.
  • Providers billing for hospice care that was unnecessary or not provided.

Since its inception in March 2007, Medicare Fraud Strike Force prosecutors filed more than 1,660 cases charging more than 3,490 defendants who collectively billed the Medicare program approximately $13 billion; 2,331 defendants pleaded guilty and 315 others were convicted in jury trials; and 2,117 defendants were sentenced to imprisonment for an average term of approximately 50 months. Strike Force teams are a key HEAT component.

By: Ronald M. Schwartz, Writer, The Remington Report