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Los Angeles Home Health Compliance Lawyers

Our federal health care lawyers and consultants provide comprehensive compliance representation for home health agencies and certifying physicians in Los Angeles. Our compliance programs have been proven to work in CMS, OIG, DOJ, and other federal agency audits and investigations.

Home health agencies in Los Angeles are under attack. The Medicare Fraud Strike Force (a joint task force with an office in Los Angeles), the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), the U.S. Department of Justice (DOJ), private auditors working with CMS, and other agencies and task forces are all actively examining Los Angeles home health agencies’ billing records to find evidence of fraud. When they uncover this evidence, they are aggressively pursuing recoupments and other penalties, and in some cases home health agency (HHA) owners and certifying physicians are facing the potential for years of federal incarceration.

As the owner of a home health agency, or as a physician who certifies patients for home health care, there is nothing you can do to escape this scrutiny. But, you can ensure that you will be safe during an audit or investigation. In the home health care sector, the key to avoiding costly penalties is comprehensive compliance. At Oberheiden, P.C., our lawyers and consultants rely on centuries of experience in the federal health care arena to help home health agencies and certifying physicians develop and implement effective compliance programs.

Medicare and Medi-Cal Compliance for Home Health Care Providers in Los Angeles

Our compliance programs are designed to comprehensively address all of the legal aspects involved in the day-to-day operation of home health agencies and the certification of aging patients for home health services. This includes full compliance with the billing regulations under Medicare, Medi-Cal (Medicaid), Tricare, and the U.S. Department of Labor (DOL) benefit programs, as well as compliance with the False Claims Act, the Anti-Kickback Statute, and all of the various other federal laws that apply to program-participating agencies and doctors in Los Angeles. 

We work closely with our clients to custom-tailor their compliance programs to their particular needs and circumstances. Within the home health sector, examples of the issues our programs typically cover include:

Issues Specific to Home Health Care (Agencies and Certifying Physicians)

1. Patient Certifications and Re-Certifications

Certifications and re-certifications present a number of legal risks for home health agencies and physicians. Medicare Form 485 requires a signature under penalty of perjury, and improper certification practices (even those undertaken in good faith) can lead to serious trouble. 

2. “Homebound” Determinations

One of the fundamental aspects of home health certification is a determination that the patient is “homebound.” While this is a medical determination, auditors and federal agents routinely second-guess certifying physicians’ and home health agencies’ determinations. As a result, all determinations must be both medically and legally sound. 

3. Provision of Skilled Services Under the Care of a Physician

In order to be eligible for program reimbursement home health care must involve the provision of skilled services, and these services must be provided under the supervision of a qualified physician. In this context, skilled services include skilled nursing care, physical therapy, speech language pathology, and continuing occupational therapy. 

4. Care Plan Establishment, Review, and Adherence 

Patients who are to receive home health care services must have a care plan that has been established and that is periodically reviewed by a physician. Except in certain circumstances, this physician cannot have a financial relationship with the home health agency. Failure to adhere to an established care plan can render all services ineligible for program reimbursement.

5. In-Person Contact Between Patients and Physicians

Medicare billing regulations require that home health care patients have a “face-to-face encounter” with their certifying physician or another qualifying doctor or nurse practitioner. Patients must have continuing in-person contact with their medical providers as well. 

6. Home Health Not Preceded by Hospital or Nursing Home Stay

In order to be eligible for home health care, a patient must generally either first receive treatment for a qualifying medical condition in a hospital (or other qualifying facility) or be transitioning out of a nursing home. A high volume of patients not meeting either of these criteria will often be viewed as a red flag by federal authorities. 

7. Primary Diagnosis Insufficient to Support In-Home Care

While conditions such as hypertension, diabetes, high blood pressure, obesity, mental illness, and pain can supplement a recommendation for home health care, none of these are independently sufficient to support a home health certification. 

8. Repeat Home Health Readmissions 

Due to the nature of home health care and the conditions for patient eligibility, readmissions should be relatively uncommon. A high percentage of patients who are readmitted multiple times within a short timeframe is a common trigger for federal investigations as well. 

9. Home Health Agency Medicare Certification

All home health agencies that bill Medicare must first receive certification from CMS. Failure to meet and maintain the criteria for certification can lead to all reimbursement claims being deemed ineligible for payment (and therefore considered “fraudulent” under the False Claims Act).

Issues for All Program-Participating Health Care Providers

1. Program Billing Compliance

From submitting an incorrect billing code to inadvertently billing for services not actually rendered, Los Angeles home health agencies must exercise extreme care to ensure that their program billings are fully compliant. Billing mistakes are among the most-common causes of penalization following audits and investigations. 

2. Patient Marketing

Relationships with marketing agencies, physicians, and other referral sources can expose home health agencies to Anti-Kickback Statute liability. All marketing agreements must be carefully structured to qualify for “safe harbor” protection. 

3. Medical Director Agreements

Medical Director (MD) agreements are often closely scrutinized by federal authorities as well. For home health agencies in Los Angeles, MD agreements with certifying physicians can be particularly problematic, as certifying physicians are prohibited from having financial relationships with HHAs. 

4. Third-Party Billing Administrator Agreements

The DOJ has made clear that health care providers cannot avoid fraud liability by outsourcing their program billings. Agreements with third-party billing administrators must include adequate representations and warranties, and they must provide clear remedies in the event that the billing administrator makes a mistake that exposes the provider to federal penalties. 

5. Documentation of Medical Necessity

Along with billing mistakes, lack of documentation is one of the most-common and most-easily-avoidable errors that can lead to substantial liability for health care providers. A comprehensive compliance program will include clear policies and procedures for creating and storing documentation of medical determinations regarding patients’ needs.

6. Response and Remedy

When health care providers identify billing errors or troubling financial relationships, a failure to act in response can be just as dangerous as the violation itself. As a result, providers’ compliance efforts must focus not only on avoiding mistakes, but also on remedying mistakes when they occur. 

7 Key Components of an Effective Home Health Care Compliance Program

With these issues in mind, it is not hard to see why Los Angeles home health agencies need to adopt comprehensive compliance programs. Within the home health sector, there are numerous issues that can lead to federal liability, and even a single shortcoming can be enough to trigger an audit or investigation and subject a home health agency or certifying physician to substantial penalties. 

As a result of our lawyers’ and consultants’ in-depth understanding of these issues, we are able to offer home health agencies and certifying physicians compliance representation specifically focused on avoiding the mistakes that federal authorities are looking for. We understand the issues from the government’s point of view, and we also have significant experience implementing compliance protocols within the real-world practice of home health care. If a compliance program cannot be executed practically, it is worth no more than the paper on which it is written. We offer our clients practical compliance solutions that allow them to bill the government with confidence. 

In our view, an effective compliance program will consist of seven key components. These components are:

  • Comprehensive Compliance Policies and Procedures
  • Compliant Third-Party Agreements
  • Practice-Wide Program Implementation
  • Documentation Plans and Storage Policies
  • Assessment, Response, and Corrective Action Plans
  • Compliance Program Review and Updating
  • Self-Reporting and Emergency Audit or Investigation Response

Complying with the Medicare, Medi-Cal, Tricare, and DOL billing requirements is not easy, but it also is not impossible. Our lawyers and consultants can take the guesswork out of the equation, and we can help you build and maintain a fully-compliant home health care practice. Whether you are preparing to open a home health agency in Los Angeles, you are a doctor who is interested in getting into the home health sector, or you have an existing home health practice with a compliance program that needs work, we can help. Schedule a complimentary initial consultation to learn more.

Schedule a Complimentary Initial Consultation at Oberheiden, P.C.

Would you like more information about home health care compliance? If so, we invite you to get in touch. To speak with a member of our federal home health care compliance team in confidence, please call 888-519-4897 or inquire online today. 

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