Consider the case of the Nurses Registry and Home Health Corporation, based in Lexington, Kentucky. Owner and Executive Director Vickie House owes $16 million to the US government for perpetrating widespread home healthcare fraud throughout her agency.
Nurses Registry engaged in systematic false billing, violating the federal False Claims Act. The staff falsified medical records to make it appear as if patients had a medical need for skilled nursing or therapy services or appear as if the patients were homebound. Employees also forged physician signatures to “certify” that the patient required home care services and re-certified patients for more and more home healthcare services, billing services long after patients stopped meeting eligibility requirements.
The agency also provided tickets to events like the Kentucky Derby and Taylor Swift concerts and delivered bottles of liquor and other “enticements” to referral sources to ensure a flow of patients. This activity violated the federal Anti-Kickback Statute and the Stark Law prohibiting home healthcare agencies from billing for services referred to them by physicians with whom they have a financial relationship. Between 2005 and 2009, Medicare paid Nurses Registry more than $100 million, with a net income to the agency of $20.5 million.
Nurses Registry owners demonstrated both full intent to commit fraud and careless disregard for the truth, wasting Medicare funds, providing unnecessary medical care to some patients and perhaps denying it to others.
Medicare discovered the nefarious activity at Nurses Registry by combing variance reports for invoicing outside of the expected dollar and procedure normal volumes and drilling down for claims specific data on the individual provider.
Plus, 2 former employees—the vice president of operations and a case manager and office administrator—blew the whistle on Nurses Registry. One of my previous articles on Whistleblowing
describes how blowing the whistle on fraud can be very lucrative. Under federal law, the whistleblowers in the Nurses Registry case are due 15% to 20% of the settlement proceeds or between $2.4 million and $3.2 million.
Health plans are duty bound to provide oversight on those providing home health services. Based on my previous experience as a case manager, to maintain proper oversight and avoid healthcare fraud, I suggest:
Reviewing the case mix of the highest paid home healthcare providers compared to their peers and asking: Do billings match the number of cases? Do any unusual patterns raise red flags?
Checking if some agencies provide a greater quantity of services for the same diagnosis without any measurable difference in outcomes;
Ensuring a case manager or utilization management staff member reaches out regularly to members in home healthcare to verify both services and outcomes, and to determine whether patients are progressing and reaching their goals;
Listening closely for staff chatting about gifts being delivered from agencies (especially around the holidays). Make sure any gifts are appropriate and don’t exceed dictated limits, influence decisions to provide services, or inflate program costs;
Confirming that the provider’s office staff are receiving all reports due from home healthcare agencies;
Monitoring customer service complaints about the services provided by particular home healthcare agencies and following up.
How many of these steps do you take regularly to maintain best practice in home healthcare services and avoid fraud?