Orange County Home Health Compliance Lawyers

Home health agencies in Orange County are being targeted by the Medicare Fraud Strike Force, the Department of Justice, and “fee-for-service” auditors working with the Centers for Medicare and Medicaid Services. Physicians that certify patients for home health care are being targeted as well. An effective compliance program is critical to avoiding Medicare and Medi-Cal fraud penalties.  

When you got into health care, the risk of being targeted in a federal fraud investigation was probably the furthest thing from your mind. Unfortunately, the exorbitant cost of Medicare and Medi-Cal fraud has resulted in the aggressive targeting of business owners and licensed professionals in all segments of the health care industry. This includes home health agencies (HHAs) and physicians who certify patients for home health services.

In order to avoid the risk of facing severe penalties as the result of an audit or investigation involving a federal agency such as the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), or the U.S. Department of Justice (DOJ), home health agencies and certifying physicians in Orange County must make compliance a top priority. This includes not only compliance with the Medicare, Medi-Cal, Tricare, and U.S. Department of Labor (DOL) billing regulations, but all of the various federal laws that apply to home health agencies and other program-participating providers. With even unintentional mistakes having the potential for severe consequences (including fines, program exclusion, and criminal prosecution), HHAs and certifying physicians must ensure that their practices are 100% compliant, and they must be prepared to demonstrate their compliance in the event of an audit or investigation. 

Lawyers and Consultants for Home Health Compliance in Orange County

Oberheiden, P.C. is a team of federal health care lawyers and consultants who have proven experience crafting and implementing effective compliance programs for home health agencies and certifying physicians. The members of our compliance team, several of whom previously served as health care fraud prosecutors with the DOJ and the U.S. Attorney’s Office, offer centuries of combined experience analyzing legal issues in the health care sector, helping health care providers make informed decisions, and favorably resolving health care fraud audits and investigations. When we develop compliance programs for our clients, we do so with an intimate understanding of both why HHAs and physicians need to be concerned about compliance and how they can avoid raising red flags. If your Orange County home health practice needs a more-effective compliance program, you can trust our team to protect you.

15 Medicare and Medi-Cal Compliance Issues for Home Health Agencies and Certifying Physicians in Orange County 

Home health agencies and certifying physicians face compliance issues that are unique to the home health sector and that apply to program-participating providers generally. We provide comprehensive compliance services focused on protecting our clients in the areas of:

1. Program Billing Compliance

Medicare, Medi-Cal, Tricare, and the DOL all have their own unique sets of billing and coding regulations. Home health agencies that bill these programs must ensure that they are submitting compliant reimbursement requests on a consistent basis. Billing and coding mistakes are among the most-common issues identified in health care fraud audits and investigations. 

2. Patient Marketing

Marketing and referral relationships present federal enforcement risks for home health agencies and certifying physicians. In our experience, the rules in this area are widely misunderstood by health care providers, and unintentional violations are common.

3. Medical Director Agreements

Medical Director (MD) agreements present federal enforcement risks under the Anti-Kickback Statute and the Stark Law. When not structured appropriately, MD arrangements can expose both the home health agency and the physician to federal prosecution. The most-common issues involve improper percentage-based compensation arrangements that result in payments being improperly made out of program-reimbursed funds. 

4. Third-Party Billing Administrator Agreements

Even if you hire a third-party billing administrator to handle your program billings, any violations will still be directly attributed to your home health agency or medical practice. As a result, billing administrators must be thoroughly vetted (are they truly “experts” in Tricare billing compliance?), and contracts with these third parties must include clear protections for the provider in the event that mistakes are made. 

5. Patient Certifications and Re-Certifications

Patient certifications and re-certifications are issues that are unique to home health care. They are also among the issues most-heavily scrutinized by auditors and federal investigators. In order to avoid penalization, HHAs and doctors must have clear policies and procedures in place that are designed to ensure compliance with the applicable certification requirements. 

6. “Homebound” Determinations

One aspect of certification involves a medical determination that the patient is “homebound.” This determination must be made based upon an in-person examination, and it must reflect a qualifying medical condition. In order to favorably respond to allegations of providing services to patients who are not truly homebound, HHAs and doctors must thoroughly document all determinations. 

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

The determination that a patient is in need of home health services must also generally follow the receipt of treatment in the traditional medical setting (i.e. a hospital) or a stay in a nursing home. Home health agencies that accept patients who do not have the requisite history of care will often be setting themselves up for costly penalties. 

8. Primary Diagnosis Insufficient to Justify In-Home Care

Even if in-home care is the best option for a patient suffering from hypertension, diabetes, high blood pressure, obesity, mental illness, or pain, these conditions are not enough to justify home health care under federal program guidelines. While these conditions can supplement a determination, they are generally insufficient to independently support a “homebound” determination.

9. Care Plan Establishment, Review, and Adherence 

Once a patient has been approved for in-home care, the HHA must work with a physician to establish a care plan. This care plan must be meticulously followed, and it must be substantively reviewed on a periodic basis. Adherence and periodic reviews should each be thoroughly documented. 

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

Home health services that are eligible for program reimbursement include skilled nursing care, physical therapy, speech language pathology, and continuing occupational therapy. If a patient’s need for one or more of these services has not been established and documented, then services cannot be billed to Medicare, Medi-Cal, Tricare, or the DOL. 

11. “Face-to-Face Encounters” Between Patients and Physicians

Home health agencies must ensure that their patients have adequate “face-to-face encounters” with their treating physicians. This includes an in-person examination prior to the beginning of in-home care, as well as sufficient ongoing doctor-patient interaction. 

12. Documentation of Medical Necessity

For all home health care services, medical necessity must be established and documented. Even if a doctor determines that a service is medically-necessary, (i) auditors or federal investigators may disagree, and (ii) if there is not documentation to prove it, then as far as the government is concerned no determination was made. 

13. Repeat Home Health Readmissions

Readmission of a patient to a home health agency is a red flag for federal authorities. Multiple readmissions are almost certain to lead to an audit or government inquiry. While there are circumstances under which readmission will be appropriate, the burden of establishing necessity falls on the readmitting HHA. 

14. Compliance Violation Response and Remedy

Even with an effective compliance program in place, it is still possible (and even likely) that mistakes will be made. When mistakes happen, the key is to respond and implement an appropriate remedy as quickly as possible. To allow for this, home health agencies’ and physicians’ compliance programs should include provisions regarding internal reporting, response, corrective action, and employee discipline. 

15. Home Health Agency Medicare Certification 

Prior to billing Medicare, home health agencies must obtain certification from CMS. This certification must be obtained lawfully (i.e. based upon the submission of complete and accurate information), and the terms of certification must be met on a continual basis in all aspects of an HHA’s practice. 

Of course, this list is not exhaustive. From Health Insurance Portability and Accountability Act (HIPAA) compliance to California licensing issues, there are numerous other issues home health agencies and certifying physicians need to address as well. At Oberheiden, P.C. our lawyers and consultants can provide you with a complete picture of your Orange County home health agency’s or medical practice’s legal obligations and provide you with a clear roadmap to compliance. We understand the burden that compliance entails; and, while certain obligations may seem unnecessary (or even antithetical to quality patient care), HHAs and doctors need to commit to 100% compliance. We can get you there, and we encourage you to contact us to learn more. 

Contact the Home Health Compliance Lawyers and Consultants at Oberheiden, P.C.

To discuss your Orange County home health agency’s or medical practice’s compliance needs, please contact us to arrange a complimentary initial compliance assessment. To speak with a member of our team in confidence, call us at (214) 469-9009 or request an appointment online today.

If you are under
investigation
you should contact us today

Contact the Experienced Attorneys of Oberheiden, P.C. Now for a Confidential Consultation

Contact Us Now