Houston Home Health Compliance Lawyers
Home health agencies and certifying physicians in Houston must adopt comprehensive compliance programs in order mitigate their risk of being audited and investigated. With centuries of combined experience, our federal lawyers and consultants can help protect your home health care practice.
Running a home health agency requires skill, dedication, and a tireless commitment to meeting your patients’ needs. It also requires a comprehensive understanding of the multitude of federal laws and regulations that apply to health care providers who bill Medicare, Medicaid, Tricare, and the U.S. Department of Labor (DOL) benefit programs. But, keeping up with these laws and regulations – and making sure you follow them – is itself a full-time job. Unfortunately, this fact has led many home health agencies in the Houston area to face severe penalties due to non-compliance.
Physicians who certify patients for home health care services face similar burdens and risks as well. The certification process is fraught with legal issues, and even simple mistakes and honest oversights can trigger invasive federal scrutiny. To protect themselves, home health agencies and certifying physicians must make federal compliance a top priority. At Oberheiden, P.C., our lawyers and consultants handle the compliance burden for home health care providers so that they can focus their time and energy on meeting their patients’ needs.
Home Health Compliance: Your Priority, Our Mission
Billing Medicare, Medicaid, Tricare, or the DOL not only subjects home health care providers to stringent (and inordinately complex) coding requirements, but it brings providers under the jurisdiction of various civil and criminal federal statutes as well. Billing errors constitute “false and fraudulent claims” under the False Claims Act, and mistakes can cost providers upwards of $11,000 for each individual billing violation. The Anti-Kickback Statute makes it illegal to pay a referral fee (or any other form of “remuneration”) out of program-reimbursed funds, and the Stark Law imposes fines and other civil penalties for physicians who engage in prohibited financial transactions.
These are just a few examples. Home health agencies and certifying physicians are also subject to other civil and criminal statutes that apply to health care providers (and other businesses and professionals) generally; and, while it may sound unthinkable, the risk of being targeted for criminal prosecution is very real. But, implementing an effective compliance program can virtually eliminate this risk, and hiring an experienced compliance team can allow you bill the government with confidence.
At Oberheiden, P.C., our mission is to help home health agencies, certifying physicians, and other health care providers avoid penalties for Medicare, Medicaid, Tricare, and DOL fraud. With offices in Houston, we routinely work with local agencies and doctors to develop and implement custom-tailored home health compliance programs. Our team of highly-experienced lawyers and consultants, which includes lawyers who previously prosecuted health care fraud cases on behalf of the U.S. Department of Justice (DOJ), offers insightful and practical solutions, and we work side-by-side with our clients until they feel ready to tackle compliance on their own.
Comprehensive Home Health Compliance Programs Developed by Highly-Experienced Federal Health Care Lawyers and Consultants
Home health care providers in Houston face unique compliance burdens. In addition to the compliance obligations that apply to health care providers generally (such as avoiding coding errors and illegal referral agreements), there are also a number of compliance obligations that are specific to home health agencies and certifying physicians. From certifications to readmissions, home health agencies and doctors must address compliance issues in all facets of the patient relationship, and they must address the legal implications of their business relationships as well.
When we represent home health agencies and certifying physicians in Houston, we work with our clients one-on-one to identify their compliance needs and develop comprehensive and customized compliance programs. Examples of the types of issues that typically need to be addressed include:
- Program Billing and Coding Compliance – As mentioned above, billing and coding compliance is a major concern for all federal program-participating health care providers. If you rely on federal funding to keep your practice running, you need to be absolutely certain that your program billings are not exposing your practice to the risk of an audit or investigation.
- Patient Marketing – Marketing is necessary to the success of any business; but, in the context of federally-funded home health care, it is also a legal minefield. Agreements and relationships with marketing firms, lead suppliers, and even other health care providers can all have potentially-dangerous implications under federal law.
- Medical Director Agreements – Medical director agreements raise potential legal concerns as well. Similar to patient marketing agreements, these agreements can be fully compliant if structured appropriately. However, they are commonly structured in ways that violate the Anti-Kickback Statute and/or the Stark Law.
- Third-Party Billing Administrator Agreements – Even if you hire a third-party billing company to handle coding for you, your practice still holds direct responsibility for federal compliance. As a result, agreements with third-party billing administrators must include adequate legal protections, including broad representations, warranties, and indemnification obligations.
- Patient Certifications and Re-Certifications – Improper patient certifications and re-certifications can create legal exposure for home health agencies and certifying physicians. Both types of providers need to have clear policies and protocols in place to ensure that all patient certifications meet the standards of federal law.
- “Homebound” Determinations – Prematurely or incorrectly identifying a patient as “homebound” is an example of a common certification-related compliance violation. If a patient is not truly confined to his or her home (according to the standards established under federal regulation), then he or she is not eligible to receive federally-funded home health care services.
- Home Health Not Preceded by Hospital or Nursing Home Stay – Another common certification-related issue involves accepting patients for home health care who have not previously been admitted to a hospital or resided in a nursing home. Home health care providers must have mechanisms in place to confirm this requirement for every patient, and this confirmation should be documented in every case.
- Primary Diagnosis Insufficient to Justify In-Home Care – Certain diagnoses, including hypertension, diabetes, high blood pressure, obesity, mental illness, and pain, are common among home health care patients. However, none of these diagnoses are independently sufficient to support a home health certification. When certifying or accepting patients with these conditions, it is imperative to document another (legally-sufficient) diagnosis as well.
- Care Plan Establishment, Review, and Adherence – Home health agencies and physicians must also document the establishment and periodic review of, and strict adherence to, patient care plans. Service provided outside of a patient’s care plan may not be eligible for federal program reimbursement.
- Provision of Skilled Services Under the Care of a Physician – In order to be eligible to receive federal funding under Medicare, a home health patient must be in need of skilled nursing care, speech language pathology services, physical therapy, or continuing occupational therapy services. If this need is not adequately documented, the requests for reimbursement may be denied (and may trigger pre-payment review of future claims as well).
- “Face-to-Face Encounters” Between Patients and Physicians – During audits and investigations, home health care providers will often be asked to provide documentation that patients have had sufficient “face-to-face encounters” with their doctors. Generating this documentation is a key component of an effective compliance program.
- Documentation of Medical Necessity – With regard to all services and physician encounters, home health care providers must have adequate documentation of medical necessity. This means both (i) determining that medical necessity exists (as defined by the applicable program guidelines), and (ii) generating records that will satisfy auditors or federal investigators.
What Does it Take for a Home Health Compliance Program to Be Effective?
Beyond simply identifying these types of issues, a home health compliance program must address these issues effectively. So, what does it take for a home health compliance program to be effective?
Documentation is key to all aspects of home health compliance. From written policies and procedures to documentation of face-to-face encounters and medical necessity, having records you can rely on is paramount to avoiding prosecution for home health care fraud.
Once a compliance program has been developed, it must be implemented. If you have documentation but you don’t follow it in all aspects of your home health practice, it is not going to protect you from federal prosecution.
All personnel should receive thorough training on their role in keeping your home health practice compliant. Information should be provided about how to report compliance violations as well.
Compliance policies and procedures should be consistently enforced in all aspects of your practice. This means holding personnel accountable, applying the relevant principles in contracts with third parties, and consistently reinforcing the importance of compliance throughout your practice.
When mistakes happen, conducting an appropriate response can be critical to mitigating the legal risks involved. Any issues should be remedied promptly, and the employees who are responsible should be disciplined appropriately.
Schedule an Initial Home Health Compliance Consultation in Houston, TX
If you would like more information about how our federal health care lawyers and consultants can help you mitigate your risk of federal prosecution through comprehensive and effective compliance, we encourage you to get in tough. To get started with a free and confidential compliance assessment, call 888-519-4897 or inquire online now.