East New York Home Health Compliance Lawyers

For home health care providers in New York’s five boroughs – Brooklyn, Manhattan, Queens, Staten Island, and The Bronx – compliance failures can have severe consequences. Our home health compliance lawyers and consultants can make sure that your practice, your license, and your personal freedom are secure.

Home health care agencies serve a vital role in our society. They provide essential care to aging patients who are unable to seek treatment in a traditional medical setting, and this service provides much-needed peace of mind to seniors and their families. However, despite filling a critical gap in our nation’s health care system, home health agencies are subject to heavy oversight by federal authorities. When these authorities conduct audits and investigations, an effective compliance program can be the key to avoiding recoupments, fines, imprisonment, and other penalties.

Compliance Lawyers and Consultants for Home Health Care Providers in East New York

At Oberheiden, P.C., our lawyers and consultants provide comprehensive compliance services to home health agencies (HHAs) and certifying physicians throughout East New York. This includes HHAs and doctors in each of New York City’s five boroughs:

  • Brooklyn
  • Manhattan
  • Queens
  • Stated Island
  • The Bronx

Our compliance services start with a thorough needs assessment. Does your home health practice’s existing compliance program largely serve its purpose? Or, are there significant gaps that must quickly be filled? Can we supplement what you already have in place, or is it time for a complete overhaul? Once we know how much work needs to be done, then we can begin the process of developing a custom-tailored home health program that you can implement in all phases of your home health practice.

Compliance Programs Focused on the Specific Needs of Medicare, Medicaid, Tricare, and DOL Home Health Providers in East New York

Home health agencies and certifying physicians that bill Medicare, Medicaid, Tricare, and/or any of the U.S. Department of Labor (DOL) health care benefit programs face a heavy compliance burden. Each of these programs has its own unique set of complex billing regulations, and all program-participating health care providers are subject to strict rules and prohibitions under federal law. Yet, while most home health care providers face the same legal challenges, in order to be maximally effective, a compliance program must be custom-tailored to the unique aspects of each individual provider’s practice. Our lawyers and consultants work closely with our clients to ensure that we are offering relevant, comprehensive, and actionable compliance advice that our clients can immediately put into practice.

So, what does it take for a home health agency or certifying physician in New York to avoid federal fraud charges as the result of an audit or investigation? Typically, our home health compliance programs focus on issues such as:

  • Program Billing and Coding Compliance – Like all health care providers, home health agencies and certifying physicians must have adequate controls in place to prevent upcoding, unbundling, phantom billing, and other common billing and coding violations. 
  • Patient Marketing – Improper marketing arrangements and referral agreements can expose home health care providers to substantial penalties under the Anti-Kickback Statute and the Stark Law.
  • Medical Director Agreements – Medical directorships present Anti-Kickback Statute and Stark Law concerns as well. This is true for the medical director and the home health agency. 
  • Third-Party Billing Administrator Agreements – Even if you engage a third-party billing administrator to handle your Medicare, Medicaid, Tricare, or DOL coding, any mistakes will ultimately remain your responsibility. 
  • Patient Certifications and Re-Certifications – Certification and re-certification practices are often at the center of home health fraud investigations. HHAs and certifying physicians must both take adequate measures to prevent improper certifications
  • “Homebound” Determinations – One issue with certifications is the determination of the patient’s “homebound” status. Certifying patients who are not truly homebound may be prosecuted as intentional health care fraud. 
  • Home Health Not Preceded by Hospital or Nursing Home Stay – Certifying patients without a hospital or nursing home stay is a red flag for auditors and federal investigators as well. Without proof of justification, certifications will be second-guessed and heavily scrutinized.
  • Primary Diagnosis Insufficient to Justify In-Home Care – Hypertension, diabetes, high blood pressure, obesity, mental illness, and pain are all common conditions among aging patients, but none of these are independently sufficient to justify in-home care. 
  • Care Plan Establishment, Review, and Adherence – All home health services must be provided pursuant to a care plan established and periodically reviewed by the patient’s physician. 
  • Provision of Skilled Services Under the Care of a Physician – In the home health care context, services that are eligible for program reimbursement include skilled nursing care, physical therapy, speech language pathology, and continuing occupational therapy. There are some fine lines, and HHAs will often need to be able to demonstrate that their billings are justified. 
  • “Face-to-Face Encounters” Between Patients and Physicians – Home health certifications should be based upon face-to-face encounters between patients and physicians (which should be meticulously documented). Home health patients must have ongoing interactions with their doctors as well (which, again, should be documented). 
  • Documentation of Medical Necessity – In all situations, home health agencies and physicians must document the medical necessity of the services they provide. Without proof of medical necessity, otherwise eligible services will not qualify for reimbursement. 
  • Repeat Home Health Readmissions – Repeated readmissions are another red flag for auditors and federal investigators. When readmitting a patient, there should be a clear basis for doing so and the grounds for the decision should be carefully documented. 
  • Compliance Violation Response and Remedy – When someone in your practice identifies a compliance violation, written policies and procedures must be followed to respond to and remedy the violation as quickly as possible. 
  • Home Health Agency Medicare Certification – Could your home health agency obtain Medicare certification today? While certification is a one-time event, failure to continually satisfy the certification criteria can be grounds for denial of payment and program exclusion. 

Documentation, Implementation, and Response: The 3 Keys to Effective Home Health Compliance

Once you know what issues you need to address, the next step is to determine how to address them. Based upon our experience with home health compliance and on both sides of federal health care fraud investigations and prosecutions, we have identified three keys to effective home health compliance:

1. Documentation of Policies, Procedures, Medical Necessity, and Compliance Efforts

Even if your home health practice is fully compliant, if you do not have the documentation to prove it, you are still going to be at risk during an audit or federal investigation. As a result, thorough documentation is at the core of any effective home health compliance program. We emphasize ensuring that our clients have the policies, procedures, proof of medical necessity, and other documentation they need in order to quickly terminate audits and investigations in their favor. This includes:

  • Practice-wide compliance policies and procedures
  • Implementation and training documents
  • Medical necessity documentation and records storage
  • Written agreements with marketing agencies, medical directors, and other third parties
  • Violation response policies and procedures
  • Internal reporting and disciplinary procedures
  • Documentation of internal compliance assessments and compliance program updates

2. Implementation of Compliance Policies and Procedures Practice-Wide

Home health agencies and certifying physicians don’t just need to have compliance policies, they need to effectively implement these policies as well. Implementation should be conducted on a practice-wide scale, and it should include policy dissemination, training, feedback, and response. If a compliance policy has been implemented effectively, all personnel should understand their role in ensuring continual compliance, they should know how to identify compliance issues and how to report them, and they should have an adequate appreciation of why compliance considerations must always remain top of mind. 

3. Identification, Response, and Remedy of Compliance Failures

Even with a comprehensive compliance program that has been fully implemented, mistakes still can and will occur. When they do, the response should be swift, and it should reflect the legal risks involved. While program-participating health care providers may have an obligation to self-report known billing violations, any self-reporting should only be conducted after thorough consultation with your home health agency’s or medical practice’s compliance counsel.

Responding to a compliance failure involves identifying the source of the failure, determining whether any systemic issues need to be addressed, and settling on a safe and effective path forward. Home health care providers must also determine whether disciplinary employment action is appropriate, and they must assess whether it is necessary to prepare for the possibility of an audit or investigation. At Oberheiden, P.C., in addition to serving as compliance counsel, we also represent New York home health care providers in audits and investigations, and we have an extensive track record of protecting our clients against civil and criminal prosecution. 

Schedule a Complimentary Home Health Compliance Needs Assessment Today

For more information about our compliance services for home health agencies and certifying physicians in New York, please contact us to schedule a complimentary home health compliance needs assessment. You can reach us by phone or online 24/7, so call (214) 692-2171 or tell us how we can help online now. 

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