Florida Home Health Agencies Fraud Attorney
When a healthcare provider becomes aware of unethical or fraudulent practices within their workplace, they face a difficult decision regarding whether to blow the whistle.
Fear of retaliation, career repercussions, and even concerns about the impact on patients’ care are enough to keep anyone awake at night. But there are laws to protect those who come forward to report wrongdoing by home healthcare agencies, ensuring that whistleblowers can make ethical decisions without fear of personal or professional repercussions.
Yormak Employment & Disability Law, led by board-certified expert Benjamin Yormak, specializes in whistleblower representation and works closely with healthcare providers who uncover home healthcare fraud. With vast knowledge of whistleblower protection laws, we offer critical expertise to ensure your rights as a whistleblower are protected. Contact us for a free consultation.
Understanding Home Health Agency Fraud in Florida
Florida’s healthcare providers are often the first to identify home health agency fraud. Two key aspects of the home healthcare system that are often manipulated are the Outcome and Assessment Information Set (OASIS) and the Home Health Resource Group (HHRG).
Outcome and Assessment Information Set (OASIS)
The Centers for Medicare & Medicaid Services (CMS) mandate that home health agencies certified by Medicare gather and send data for all adult patients funded by Medicare and Medicaid.
The system used to define standardized data is called OASIS (Outcome and Assessment Information Set), which is crucial for determining home healthcare payments and helping healthcare providers determine patient needs and devise care plans. In some cases, home health agencies will deliberately manipulate the data entered into OASIS with the intent to defraud the Medicare and Medicaid systems.
Home Health Resource Group (HHRG)
HHRG, also known as case-mix, refers to a classification system developed and overseen by the CMS. The HHRG system is a part of the Medicare Home Health Prospective Payment System (HH PPS), which determines reimbursement rates for home health agencies providing services to Medicare beneficiaries.
The HHRG classification is determined based on the data collected through the OASIS system. The data evaluates a patient’s impairment level and service use, while the HHRG score, calculated upon completion of the assessment, determines reimbursement rates and the level of home health provided.
The HHRG score can be manipulated by billing for services not rendered, upcoding, unbundling, or providing unnecessary care, for example. Whistleblowers play an essential role in identifying and reporting this type of fraud.
Common Home Healthcare Fraud Whistleblower Claims
Billing for Services Not Rendered
Billing for unprovided services in home healthcare is a red flag. This can include invoicing for procedures, tests, or treatments that never took place or home healthcare hours that were not fulfilled.
Upcoding in home healthcare refers to submitting codes for more severe and expensive diagnoses or procedures than what was provided to the patient, allowing home health agencies to receive higher reimbursement from Medicare, Medicaid, or private insurers.
Unbundling in the context of home healthcare consists of billing for individual services or procedures separately instead of submitting them as a bundled package. This is done to increase reimbursement amounts.
Providing Unnecessary Care
This type of fraud involves recommending services that are not medically necessary for the patient, resulting in financial gain for the agency. Examples of unnecessary care in home healthcare include authorizing medically unnecessary services or falsifying symptoms that would justify a certain procedure or care service.
Home health agencies may falsify patient records or other documentation to support fraudulent billing practices. Home health agencies in Florida might submit false requests for home health services, forging reimbursement claims, or falsely certifying patients as home-bound.
Kickbacks involve incentives given to healthcare providers in exchange for patient referrals or other business. Florida law defines healthcare kickbacks as the offering, paying, soliciting, or receiving a commission, benefit, bonus, or bribe, directly or indirectly, intended to generate healthcare business.
Patient recruiting involves enrolling ineligible patients into home health services for financial gain. This scheme is a serious violation of healthcare regulations and ethical standards and involves recruiters getting paid by home health agencies to refer Medicare beneficiaries for home health services billed to Medicare.
Medicare fraud encompasses various practices within the home healthcare industry that result in financial loss to the Medicare program. The most common forms of Medicare fraud in the home healthcare industry in Florida include submitting false claims, billing for services that are not required, upcoding, and kickbacks.
Whistleblower Claims and Home Health Agency Fraud
Whistleblower claims play a crucial role in uncovering home health fraud. Qui tam lawsuits, the False Claims Act, and whistleblower rewards encourage whistleblowers to step forward.
Qui Tam Lawsuits
Qui Tam Lawsuits allow whistleblowers to file claims on behalf of the government, potentially resulting in financial rewards for successful cases. It’s important to note that these lawsuits can be complex and require expert legal guidance, which is why potential whistleblowers are advised to seek out experienced attorneys before proceeding.
The False Claims Act
The False Claims Act is a federal law that imposes civil and criminal penalties on individuals and organizations that knowingly submit false claims to government programs, including Medicare. Penalties for healthcare fraud under the False Claims Act can be brought by whistleblowers who know of fraudulent activities.
Home Healthcare Agency Fraud Whistleblower Rewards
Government rewards for whistleblowers reporting home healthcare fraud can range from 15-30% of the recovered amount. Whistleblower rewards can be a strong incentive for individuals with knowledge of home healthcare fraud to report it. These rewards provide financial compensation to whistleblowers and play a critical role in encouraging fraud reports.
Contact Us for a Free Consultation
If you are aware of home health agency fraud and are considering filing a whistleblower claim, don’t hesitate to contact Yormak Employment & Disability Law for a free consultation. Our experienced team will provide the legal counsel and representation you need to navigate Florida whistleblowing laws.