Defending Against Allegations of Home Health Care Fraud

Defending Against Allegations of Home Health Care Fraud

Common Triggers for Fraud Investigations

There are several red flags that may trigger audits or fraud investigations of home health agencies by the Centers for Medicare & Medicaid Services (CMS), Department of Justice (DOJ), and other agencies:[1]

  • Improper certifications or recertifications – Failing to adequately document patient eligibility and medical necessity for home health services on CMS Form 485 and other records. Using inappropriate diagnostic codes or conditions like hypertension that do not qualify.
  • Unlawful marketing arrangements – Paying recruiters contingent on number of patients referred, having no written contracts, or other non-transparent practices.
  • Sham medical director agreements – Paying medical directors kickbacks disguised as compensation with little or no supervision of patient care.
  • Billing errors – Upcoding services actually provided or billing for services not rendered due to poor internal controls. Even innocent mistakes may lead to fraud charges.
  • Lack of compliance program – Not having formal policies, training, auditing procedures, and other compliance tools leaves agencies vulnerable if issues arise.

Building an Effective Legal Defense Strategy

As an experienced home health care lawyer, I have successfully defended many clients wrongly accused of fraud. A strong defense requires proactively investigating the allegations, assessing risks, and telling our client’s side of the story. Key aspects of an effective strategy include:[2]

  • Conducting an internal audit – Thoroughly review patient records, certifications, billing records, employee conduct, marketing arrangements, and all aspects of operations to identify any actual compliance gaps versus innocent mistakes.
  • Assembling the right defense team – Include experienced health care attorneys as well as medical billing experts, auditors, therapists, nurses and other professionals to evaluate issues and serve as witnesses.
  • Negotiating with authorities – Be proactive in presenting our findings and working cooperatively with auditors, federal agents, or prosecutors to correct any actual issues uncovered while contesting unfounded allegations.
  • Litigating when necessary – If settlement negotiations fail and the government pursues formal civil penalties or criminal charges, vigorously contest them in court utilizing legal defenses and testimony from our expert witnesses.
  • Implementing a compliance program – Regardless of the outcome, using the audit findings to strengthen internal compliance policies and controls can demonstrate good faith and prevent issues in the future.

By taking an aggressive and multifaceted approach to defending home health agencies, I have achieved many favorable settlements and court verdicts for clients facing fraud allegations and helped protect their business reputations and professional licenses from unjust consequences. No two cases are alike, but skillful advocacy can make the difference between a minor compliance correction or a catastrophic criminal conviction.

Real-World Examples and Outcomes

To illustrate how these defense strategies play out in actual cases, here are some examples of home health fraud allegations I have successfully refuted:[3]

  • A Michigan agency owner was accused of paying kickbacks for patient referrals. We proved the patients qualified for services and she received inaccurate legal advice about marketing agreements. Charges dismissed.
  • Prosecutors claimed a Los Angeles doctor referred ineligible patients to home health agencies for payments. Our audits found the patients were properly diagnosed and needed care. Charges reduced to civil fines.
  • The government sought $8 million in penalties from a Texas agency for services deemed medically unnecessary. Our documentation validated the medical needs. Liability limited to $200,000 settlement.
  • An Illinois agency owner was indicted for fabricating patient records and credentials. We discovered a rogue employee committed the fraud without the owner’s knowledge. Charges dropped after compliance fixes made.

As these cases highlight, skilled legal advocacy makes a major difference when battling home health fraud allegations. An experienced attorney can identify weaknesses in the government’s claims, present evidence disputing their theory of fraud, negotiate reduced penalties or dismissal of charges, or successfully defend the case at trial. With so much at stake, building an aggressive defense is critical, even if it ultimately leads to some operational changes.