Fraud and Abuse Compliance

by Elizabeth E. Hogue, Esq. | Dec 18, 2025 | Admin, Home Health, Hospice, Legal

by Elizabeth E. Hogue, Esq.

Fraud and Abuse Compliance

Why All Providers Should Have One

Providers may have heard or read about the importance of Fraud and Abuse Compliance Programs in their organizations. Despite the wealth of available information about Compliance Programs, many providers continue to express uncertainty about their value.

Coincidentally, as we are preparing to publish this article, HHS publishes this report on the compliance audit of Guardian Home Care, LLC.

Here are some of the questions providers often ask about Compliance Programs:

Why should we have a Fraud and Abuse Compliance Program?

First

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has clearly stated that all providers are now required to have current Compliance Programs that are fully implemented.

As a practical matter, when providers establish and maintain Compliance Programs, it clearly discourages regulators from pursuing allegations of fraud and abuse violations. Jody Hunt, formerly of the DOJ, says providers should create robust fraud and abuse compliance programs. Then providers can argue that they shouldn’t be liable for violations because their compliance programs demonstrate that they had no intent to commit fraud.

Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Programs is considered to be a mitigating factor. That is, if accusations of criminal conduct are made, the consequences may be substantially less severe as a result of a fully implemented Compliance Program.

Additionally

Providers with Compliance Programs are more likely to avoid fraud and abuse. This is because Programs routinely establish an obligation on the part of every employee to report possible instances of fraud and abuse and include training for all employees.

Compliance Programs may also help to prevent qui tam or so-called “whistleblower” lawsuits by private individuals, rather than by government enforcers, who believe that they have identified instances of fraud and abuse. There are significant incentives to bring these legal actions since “whistleblowers” receive a share of monies recovered as a result of their efforts. Some “whistleblowers” have received millions of dollars. Compliance Programs make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first.

Also…

The federal Affordable Care Act (ACA) requires providers to have Compliance Programs. In short, it’s the law!

Finally

The Deficit Reduction Act (DRA) requires providers who receive more than $5 million in monies from state Medicaid Programs per year to implement policies and procedures, provide education to employees and put information in their employee handbooks about fraud and abuse compliance. These requirements can be met through implementation of Fraud and Abuse Compliance Programs.

We don't receive reimbursement from the Medicare or Medicaid Programs.

Do we still need a Compliance Program?

Statutes and regulations governing fraud and abuse also apply to providers who receive payments from any federal and state healthcare programs, including Medicaid, Medicaid waiver and other federal and state health care programs, such as Tri-Care. Many private insurers have followed the federal government’s “lead” in terms of fraud and abuse enforcement. So private duty providers must have compliance programs, too.

Should we just use the model guidance that is applicable to us?

We hear that the OIG has provided guidance for various segments of the healthcare industry regarding Compliance Programs. Specifically, the OIG has already published guidance for clinical laboratories, hospitals, home health agencies, skilled nursing facilities (SMFs), hospices, physicians’ practices, third-party billing companies and home medical equipment companies. The OIG will publish updated guidance for all providers, It has already done so for SNFs.

The answer is “No!” Guidance from the OIG is not a model Compliance Program. Guidance from the OIG consists of general guidelines and does not constitute a valid Compliance Program. In addition, the OIG has made it clear that Programs must be customized for each organization.

Do we have to conduct internal audits first?

We have read that, before implementing Compliance Programs, providers must conduct expensive internal audits that can take many months to complete. Is this true?

While beginning the compliance process with an extensive internal audit is certainly one way to proceed, it is not the only viable way to work toward compliance. It is equally valid to begin with Compliance Programs that are customized for the organization that includes training for all employees about fraud and abuse and Compliance Programs. Then all staff members can subsequently participate in internal compliance activities, including audits, with a process in place to handle any issues that arise as a result of the audits.

We already have policies. Why do we need a Compliance Program too?

Compliance Programs are specific types of documents that routinely address issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits under the Federal Sentencing Guidelines described in the first question above if there is no formal document called a Compliance Program.

We're accredited. Doesn't that mean we are in compliance?

On the contrary, Compliance Programs appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance such as processes for identification and correction of potential problems that are not addressed during the certification process. In other words, organizations may be accredited but fail to meet applicable compliance standards for fraud and abuse.

Will it help with investigations?

Will the fact that our organization has a Compliance Program make any difference with regard to the outcome of fraud and abuse investigations and the imposition of Corporate Integrity Agreements (CIA’s)?

Yes, it may make a considerable difference based on statements from the OIG. If providers have Compliance Programs in place that are current and fully implemented, the OIG may be less aggressive in pursuing potential violations. When the OIG actually discovers problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). The OIG often requires CIA’s to include a process for stringent monitoring by the OIG on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Programs are not necessarily asked to develop and implement CIA’s.

Final Thoughts

Now is the time for all providers to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

No portion of this material may be reproduced in any form without the advance written permission of the author.

DOJ Settles with UnitedHealth and Amedisys

by Kristin Rowan | Aug 21, 2025 | Legal, M&A, Medicare, Medicare Advantage

by Kristin Rowan, Editor

DOJ Settles with UnitedHealth and Amedisys

Judge to Weigh In

DOJ settles with UnitedHealth and Amedisys after almost nine months of negotiations. The Department of Justice (DOJ) initially blocked the proposed merger between UnitedHealth and Amedisys, citing concerns over eliminating competition in home health and hospice services in some areas of the U.S. After the most recent settlement hearing, the merger seems to be back on track.

Public Comment Period and Judicial Review

Now that the DOJ hurdle has been passed, there is a public comment period. Following the public comment period, the U.S. District Court for the District of Maryland will enter final judgement. From the Justice Department website:

As required by the Tunney Act, the proposed settlement, along with a competitive impact statement, will be published in the Federal Register. Any interested person should submit written comments concerning the proposed settlement within 60 days following the publication to Jill Maguire, Acting Chief, Healthcare and Consumer Products Section, Antitrust Division, U.S. Department of Justice, 450 Fifth Street NW, Suite 4100, Washington, DC 20530.

Antitrust Division Statement

“In no sector of our economy is competition more important to Americans’ well-being than healthcare. This settlement protects quality and price competition for hundreds of thousands of vulnerable patients and wage competition for thousands of nurses. I commend the Antitrust Division’s Staff for doggedly investigating and prosecuting this case on behalf of seniors, hospice patients, nurses, and their families.”

Abigail Slater

Assistant Attorney General, Justice Department Antitrust Division

Divestiture Agreement

According to the new agreement, UnitedHealth will sell 164 home health and hospice locations across 19 states. In addition to the sale, the agreement provides the buyers of these locations with assets, personnel, and relationships to help them compete with remaining UnitedHealth locations. Also included are protections to deter UnitedHealth from interfering with the new owners’ ability to compete.

BrightSpring Health Services and Pennant Group will acquire the 164 locations. Slater said the settlement, which includes the largest ever divestiture of outpatient healthcare, protects quality and price competition patients as well as wage competition for nurses. However, antitrust specialist Robin Crauthers, a partner with McCarter & English, says it doesn’t go far enough. According to Crauthers, the settlement agreement does not address all of the markets that would have less competition and that the DOJ accepted less than they wanted in the agreement.

Additionally, critics argue the divestiture moves 164 home health and hospice agencies from one large player to two other large players in the space. Arguably, rather than preserve competition, this divestiture agreement will only serve to strengthen the largest players in the market, giving them a substantial advantage over smaller agencies in these areas.

UnitedHealth Amedisys divestiture locations

Not the Only Concern

Vertical Integration

Joe Widmar, Director of M&A at West Monroe consulting firm, says that the number of home health and hospice agencies is not the tipping factor in competition. Rather, it is UnitedHealth’s vertical integration. A health insurance company that also owns nearly 2,700 subsidiaries, including pharmacies, home health and hospice, behavioral health, consulting for healthcare organizations, surgery centers, hospitals, mental health, managed care for Medicaid and Medicare, and specialty care. Virtually any referral from a PCP to any other health professional puts more money into the health care giant’s pockets. The lack of competition is across all forms of healthcare, leaving patients no choice buy to support UnitedHealth Group in areas where all local healthcare providers are subsidiaries. I 2024, UnitedHealth insurance paid $150.9 million to its subsidiaries for care. These provider companies are not counted in the profit caps placed on insurance companies.

Upcoding

In addition to side-stepping profit caps, vertical integration aids in upcoding. Upcoding is the practice of digging into a patient’s life to find (or create) additional patient needs. Insurers add as many codes as possible for the greatest reimbursement rates. According to a recent study, UnitedHealthcare overbilled Medicare Advantage by $14 billion through upcoding.

In-home health risk assessments and patient reviews, often offered to beneficiaries as a free service, result in an average risk score 7% higher than in patients seen in medical practices and hospitals. UnitedHealth generates more income from patient review diagnoses than any other MA insurer. The Department of Justice is currently investigating UnitedHealth’s Medicare billing practices.

Final Thoughts

If you own a home health, hospice, or palliative care agency in any of the states shown in the graphic above, write to Jill Maguire with comments and concerns. Our primary objective is providing quality care to patients in their homes. We know that home care is less expensive for the patient and government-funded insurance. But not when all the home care agencies in an area are owned by only a few of the largest home health agencies in the country. And not when the insurer is adding diagnostic codes to pad their bill.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Fraud, Waste, and Abuse

by Kristin Rowan | Jul 10, 2025 | Clinical, CMS, Home Health, Legal, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Fraud, Waste, and Abuse

DOJ, HHS False Claims Act

Fraud, Waste, and Abuse has become something of a mantra within the Department of Health and Human Services (HHS). Secretary Kennedy has committed to combatting fraud, waste, and abuse within the federal healthcare system. The Department of Justice (DOJ) and HHS have a long history of working together to combat healthcare frauding under the False Claims Act (FCA).

Working Group

In furtherance of their goal to combat healthcare fraud, HHS and DOJ have formed the DOJ-HHS False Claims Act Working Group. The Working Group will include leadership from the HHS Office of General Counsel, CMS Center for Program Integrity, the Office of Counsel for the OIG, and the DOJ Civil Division.

Working Group Priorities to Combat Fraud, Waste, and Abuse

1. HHS will refer potential False Claims Act violations to the DOJ that are in line with the Working Group priority enforcement areas:

Medicare Advantage
Drug, device, or biologics pricing
- arrangements for discounts, rebates, service fees, and formulary placement and pricing reporting
Barriers to patient access to care
- violations of network adequacy requirements
Kickbacks related to drugs, medical decives, DME, and other products paid for by federal healthcare programs
Materially defective medical devices that impact patient safety
Manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services

2. The Working Group will maximize collaboration to expedite investigations and identify new leads. They will leverage HHS resources using data mining and assessment of findings.

3. The Working Group will discuss implementing payment suspension according to the CMS Medicare Program Code of Federal Regulations¹

4. The Working Group will discuss whether DOJ will dismiss a whistleblower case under the U.S. Code for Civil actions for False Claims, pursuant to the DOJ Manual for Civil Fraud Litigation²

Report Fraud, Waste, and Abuse

The Working Group encourages whistleblowers to report violations of the False Claims Act within the priority areas. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477). Similarly, the Working Group encourages healthcare companies to identify and report such violations.

²DOJ Dismissal of a Civil Qui Tam Action. When evaluating a recommendation to decline intervention in a qui tam action, attorneys should also consider whether the government’s interests are served, in addition, by seeking dismissal pursuant to 31 U.S.C. § 3730(c)(2)(A).

¹Suspension of payment. The withholding of payment by a Medicare contractor from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists, or until the resolution of an investigation of a credible allegation of fraud.

# # #

DOJ Rejects Plan

by Kristin Rowan | May 16, 2025 | M&A, Regulatory

by Kristin Rowan, Editor

DOJ Rejects Plan to Divest Assets

DOJ rejects plans to divest assets from UnitedHealth and Amedisys to BrightSpring Health Services and the Pennant Group. Last week, we reported that Amedisys and UnitedHealth had entered an agreement to divest certain home health and hospice agencies to satisfy anti-trust concerns. The plan is contingent on the finalization of the merger between UnitedHealth and Amedisys.

Divesting Assets

The merger between UnitedHealth and Amedisys has been ongoing since last summer. Shortly after the announcement, the Department of Justice sued under anti-trust allegations to stop the merger. According to the DOJ, even if the companies offload the 120 planned locations, it would not safeguard competition in home health and hospice markets. The DOJ cited overlap in certain markets where UnitedHealth and Amedisys both currently have agencies.

This could spell T-R-O-U-B-L-E

Following the lawsuit, Amedisys and UnitedHealth started talks with VitalCaring to divest properties. That deal fell through after VitalCaring lost its own lawsuit last year. This latest blow could stall the merger altogether. The DOJ reportedly rejected the divestiture stating that it wasn’t enough. Unless Amedisys and UnitedHealth divest more properties in certain markets, the DOJ is unlikely to approve the merger.

Mediation

The parties are scheduled to enter mediation on August 18th. The judge has now scheduled a follow-up mediation appointment on August 25th, anticipating that one day of mediation will not resolve the lawsuit. Amedisys and UnitedHealth have 90 days to secure additional divestiture that will satisfy the DOJ before mediation begins.

This is an ongoing story and The Rowan Report will continue to bring you the latest news on the merger. Please see our accompanying articles this week on the new UnitedHealth CEO and the new DOJ investigation on UnitedHealth Group.

# # #

New Deal to Sell HH & Hospice Agencies

by Kristin Rowan | May 9, 2025 | M&A

by Kristin Rowan, Editor

UnitedHealth, Amedisys to Divest Home Health & Hospice...Again

History

UnitedHealth, Amedisys to divest home health and hospice properties to satisfy DOJ. Almost two years ago, the health services division of UnitedHealth Group, Optum, announced plans to by Amedisys. The purchase announcement came after Optum outbid Option Care Health with an unsolicited offer. The Department of Justice launched an anti-trust probe shortly after the announcement. To satisfy the DOJ, UnitedHealth and Amedisys plan to divest some of its businesses as part of the acquisition agreement.

Anti Anti-Trust

We previously reported that Amedisys entered into an agreement with VitalCaring to divest some of its home health and hospice locations. This agreement was meant to satisfy the DOJ concerns raised in its anti-trust lawsuit against Amedisys and UnitedHealth.

In January of 2025, VitalCaring lost a lawsuit filed by Encompass Health and Enhabit and were ordered to pay 43% of all future profits to the two companies. In the wake of that court decision, VitalCaring pulled the agreement and signed a mutual release with UnitedHealth, with all parties walking away from the deal.

BrightSpring

BrightSpring Health Services is an $11.5B company with locations across the United States and employing more than 37,000 people. In January of this year, BrightSpring sold is Community Living Business to Sevita. BrightSprings intends to acquire additional properties, focusing on its home- and community-based businesses. According to the BrightSpring President and CEO Jon Rousseau, BrightSpring is “focused on getting to 3x leverage within the next two years.”

Amedisys operates in 38 states with more than 500 locations. The document Amedisys submitted to the SEC does not indicate how many of its properties and those of UnitedHealth will be divested. A UnitedHealth statement said the company plans to divest at least 128 home health and hospice facilities.

One has to wonder whether we are trading one monopoly for another.

New Deal

As the DOJ lawsuit enters mediation this August, UnitedHealth and Amedisys search for another way to divest its properties. Enter the New Deal. BrightSpring Health Services, parent company to Adoration Home Health Acquisition LLC, Adoration Hospice Care Acquisitions LLC and Senescence LLC, DBA All Saints Hospice will purchase some of the properties from both Amedisys and UnitedHealth. The Pennant Group, parent company to Cornerstone Healthcare, Inc. and Tensaw River Healthcare, LLC, will purchase additional properties from bother companies.

According to documents submitted to the Securities and Exchange Commission (SEC), both agreements have mulitple contingencies, including the finalization of the UnitedHealth/Amedisys merger. Financial information on the two deals was not included in the Amedisys SEC filing. In a separate filing, Pennant valued their part of the agreement at nearly $102.5 million.

No Deal Yet

The sale of properties to BrightSpring and Pennant Group relies on the finalization of the merger between Amedisys and UnitedHealth. A magistrate will oversee mediation between the two companies and the DOJ beginning this August.

The SEC and the DOJ have not yet responded to the intent to divest to BrightSpring and Pennant Group.

Final Thoughts

The proposed merger between UnitedHealth and Amedisys has been ongoing for two years. The two companies, who previously stated their competition helped keep them honest and keep costs low, now state that the merger will lower costs even more. The DOJ disagrees. To alleviate concerns, the merger includes the release of properties anywhere the merger would create an unfair advantage. Mediation in August will reveal more on the position of the DOJ, the response from UnitedHealth and Amedisys, and the specifics of the divestment of home health and hospice agencies. The merger proposal expires December 31, 2025. We will continue to follow the story as the parties enter mediation.

# # #

UnitedHealth Group Amedisys Merger Faces Further Delays

by Kristin Rowan | Jan 9, 2025 | M&A, Regulatory

by Kristin Rowan, Editor

UHG and Amedisys Waive Termination

The UnitedHealth Group and Amedisys merger has been an ongoing story since the initial merger agreement was signed in June of 2023. The proposed merger came under scrutiny by the Federal Trade Commission (FTC) and the Department of Justice (DOJ). UnitedHealth Group and Amedisys are competitors in the home healthcare market and the merger would hurt patients.

“UnitedHealth’s plan to extinguish Amedisys as a competitor is the result of an intentional, sustained strategy of acquiring, rather than beating, competition.”

Department of Justice

DOJ Pushes Back

Late in 2024, the DOJ filed a lawsuit against the merger, claiming that both companies have acknowledged that their competition helps keep them honest and drive quality both in patient and employee care. The DOJ noted that the acquisition would be presumptively illegal in multiple markets. UHG, Amedisys, and Optum proposed selling off some of its care centers to address the concerns about competition.

Merger Deadline Reached

Under the initial merger agreement, UHG would pay $3.3 billion to acquire Amedisys, which would remain as a subsidiary of UHG. That agreement was set to be finalized on December 27, 2024. There has been no decision made on the DOJ lawsuit, so the merger could not be completed. UHG and Amedisys have mutually agreed to extend the merger and added a break fee of $275 million.

Indefinite Merger Extension Through 2025

The new agreement has an indefinite ending. According to the wording, the merger agreement will now expire either on December 31, 2025 or 10 days after a final court decision in the lawsuit, whichever comes first.

According to the new filing with the SEC, UnitedHealth and Amedisys will be divesting assets to secure the merger and satisfy the DOJ. If not, they will incur a break fee of up to $325 million. Both companies have an agreement with VitalCaring Group to acquire the necessary assets.

What If?

If…The Trump administration is less stringent in antitrust matters, as expected.

The lawsuits currently at the U.S. District Court and five states will likely fail.

If…the U.S. District Court for the District of Maryland either decides to block the merger permanently or does not reach a final order by the end of the year…

The merger agreement will expire.

If…UnitedHealth Group, Optum, and/or Amedisys fails to divest holdings…

The merger agreement will not satisfy the antitrust regulations and the failing party will pay hundreds of millions in damages, and the merger agreement will end.

This is an ongoing story and we will continue to report on updates as they occur. See our accompanying BREAKING NEWS story.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

UnitedHealth Group Acquisition of Amedisys Under Fire by DOJ

by Kristin Rowan | Nov 15, 2024 | CMS, M&A, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Justice Department Sues

In September of 2023, UnitedHealth Group made a bid to purchase Amedysis. That acquisition has been under scrutiny since last year. When the bid was announced, the Department of Justice began an inquiry, asking for additional information. At the time, Amedysis indicated that they anticipated the inquiry.

Now, more than a year later, the Department of Justice, along with the Attorneys General of Maryland, New York, New Jersey, and Illinois, have filed an antitrust lawsuit to block the acquisition. The proposed $3.3 billion acquisition would eliminate competition between the two companies. It would also give too much control to UnitedHealth Group, according to the suit.

Statement from the Department of Justice

The DOJ and the Attorneys General stated that the merger is illegal. The two companies own so much of the market share in the space already that combining the two would mean less choice for patients and fewer employment options for nurses seeking competitive pay and benefits.

UnitedHealth Group already acquired Amedisys’s biggest home health and hospice rival, LHC Group. Since that acquisition, UnitedHealth Group and Amedisys have been two of the largest providers of home health and hospice care in the United States.

American healthcare is unwell. Unless this $3.3 billion transaction is stopped, UnitedHealth Group will further extend its grip to home health and hospice care, threatening seniors, their families and nurses.

Jonathan Kanter

Assistant Attorney General, Justice Department anti-trust division

Surprisingly, the former CEO and current board chairman of Amedisys acknowledged the problems. He said that the competition between the two companies has helped keep them honest. He also said it has driven better quality to the benefit of their respective patients. The former CEO went on to say that the companies also compete for nurses and the merger may threaten the benefits nurses receive. It seems even the heads of the companies involved know this is a bad idea.

UnitedHealth Group's Proposed Solution

In response to the concerns voiced by the DOJ, UnitedHealth proposed to divest some of its facilities to VitalCaring Group. UnitedHealth said this would prevent the monopoly the merger creates. The DOJ responded to that proposal somewhat harshly.

The complaint alleges that the UnitedHealth Group’s market share would be illegal in home health markets in 23 states and the District of Columbia. It would also be illegal in hospice markets in 8 states, and in the nurse labor market in 24 states.

UnitedHealth’s proposed divestiture would only alleviate the monopoly in a few areas. This leaves hundreds of markets across the U.S. in jeopardy. Further, VitalCaring Group has poor quality scores and is facing its own legal judgement of close to half a billion dollars. Allegedly, the current CEO of VitalCaring Group was the CEO of a competitor while running VitalCaring behind the scenes.

Good News for Home Health and Hospice

The complaint describes home health and hospice services as “critically important parts of the American healthcare system….Patients rely on the skill and expertise of home health and hospice nurses, who must effectively treat patients at home.

Millions of patients depend on United and Amedisys to receive home health and hospice care in the comfort of their homes. The Department’s lawsuit demonstrates our commitment to ensuring that consolidation does not threaten quality, affordability, or wages in these vital healthcare markets.

Benjamin C. Mizer

Principal Deputy Associate Attorney General

Attorney General Merrick B. Garland said, “We are challenging this merger because home health and hospice patients and their families experiencing some of the most difficult moments of their lives deserve affordable, high quality care options. The Justice Department will not hesitate to check unlawful consolidation and monopolization in the healthcare market that threatens to harm vulnerable patients, their families, and health care workers.”

Final Thoughts

Mister Attorney General, please turn your attention to CMS and Medicare Advantage, as they continue to threaten the safety and well-being of patients, families, and caregivers with increasingly low reimbursement rates and denials of coverage.

# # #

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

HHA to pay Nearly $4 Million after False Claims Act Violations

by Kristin Rowan | Aug 23, 2024 | Regulatory

by Kristin Rowan, Editor

False Claims Act Violations

According to allegations in U.S. es rel. Jones v Intrepid U.S.A. Healthcare Inc. and U.S. es rel. Rigney v Intrepid U.S.A. Inc., Intrepid U.S.A. Inc. (Intrepid) violated the False Claims Act multiple times over five years.

Intrepid is based in Texas and includes more than 80 Personal Care, Home Health, Palliative Care, and Hospice Care agencies across 18 states. Intrepid describes their services as “concierge medical home healthcare, hospice at home, private duty home care, and independent living support.”

Whistleblowers

Whistleblowers filed Civil cases against Intrepid under the whistleblower provisions of the False Claims Act. A former travel nurse and a former Director of Quality and Improvement for Intrepid filed the first case. A former Director of Clinical Excellence and Integrity and a former Regional Manager of Clinical Excellence for Intrepid filed the second. Under the False Claims Act, a private party can file an action against a company on behalf of the United States. Should there be a settlement or resolution, the filing party(ies) receive a portion of any recovery.

Allegations

Each of the cases addresses different lines of business for Intrepid. The first case alleges that Intrepid knowingly submitted home healthcare Medicare claims for patients who did not qualify for the home healthcare benefit, or where services did not qualify for reimbursement. The second case alleges that Intrepid knowlingly submitted Medicare claims for patience who did not qualify for the hospice benefit.

More Allegations

Additionally, the United States claims that from 2016 to 2021, Intrepid submitted claims for services that were not reasonable or medically necessary, services provided by untrained staff, and services that were never provided at all. Separately, the United States alleges that Intrepid admitted patients who were ineligible for hospice benefits because they were not terminally ill and continued providing services to patients who should have been discharged because they no longer met the requirements to qualify for the hospice benefits.

Settlement

The Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Western District of Kentucky and U.S. Attorney’s Office for the District of Minnesota worked together to investigate and resolve these matters. According to the Department of Justice report, no liability or admission of guilt was determined and the settlement resolved allegations only.

Repeat Offender

It seems this is not the first run-in with the law that Intrepid U.S.A. has faced.

2014: a class action suit alleged unpaid wages.

2019: Intrepid settled a class action suit where employees alleged unpaid overtime.

2021: William Buchanan filed a civil right – employment discrimination suit against Intrepid in Indiana.

Intrepid in Minnesota and North Carolina faced similar Medicare fraud charges as well.

Not Alone

Intrepid U.S.A. Inc. is not the only home health or hospice agency to face these types of allegations.

Evolution Health LLC

In July, 2024, Guardian Health Care, Inc., Gem City Home Care LLC, and Care Connection of Cincinnati LLC, together with their parent company Evolution Health LLC, settled a False Claims Act case in which the Companies were accused of providing illegal kickbacks to ALFs and physicians in exchange for referrals. That settlement totaled almost $4.5 million dollars.

Halo Home Healthcare

Similarly, in June, 2024, the former owner of Halo Home Healthcare pled guilty to billing more than $8.5 million in fraudulent claims to Medicare, Medicaid, and Veterans Affairs from 2015 to 2021. Halo Home Healthcare hired more than 50 employees with criminal backgrounds that should have excluded them from providing home health services, one of whom was charged with a quadruple murder during their employment at Halo. The former owner also hid her ownership of the company because she had been convicted in 2013 of passing forged and fraudulent prescriptions for oxycodone and hydrocodone.

Atlantic Home Health Care

In January, 2024, Atlantic Home Health Care was accused of falsely billing the Energy Employees Occupational Illness Compensation Program. The claim alleges Atlantic charged for in-home nursing and personal care when employees weren’t providing services and paying kickbacks for patient referrals. The Arizona-based company paid almost $10 million to resolve that case.

Speak Up, Speak Out

Fraudulent billing, up-coding, and other illegal acts from home health and hospice agencies put additional strain on the already stretched CMS budget for reimbursement. The millions of dollars recovered just this calendar year is just a portion of fraudulent claims filed. Whistleblower laws protect employees from retaliation by their employers. Fraudulent practices that send money directly to an agency without benefitting a patient hurts the whole industry. The only way the Department of Justice can address and stop these billing practices and keep that money going directly to patient care is with the help of whistleblowers.

# # #

Ohio HHA Violated Anti-Kickback Statute

by Rowan Report | Jul 19, 2024 | Partner News

FOR IMMEDIATE RELEASE

Office of Public Affairs

July 1, 2024 — Guardian Health Care Inc., Gem City Home Care LLC and Care Connection of Cincinnati LLC, home health agencies operating in Texas, Ohio and Indiana, along with their owner Evolution Health LLC (together, the Companies), have agreed to pay $4,496,330 to resolve allegations that they violated the False Claims Act by knowingly providing illegal kickbacks to assisted living facilities and physicians in exchange for Medicare referrals.

This settlement resolves allegations that, from 2013 to 2022, Guardian Health Care, Gem City Home Care and Care Connection of Cincinnati provided lease payments and other valuable benefits, including wellness health services, sports tickets and meals, to numerous assisted living facilities and their residents, as well as certain health care providers, in exchange for referrals of Medicare beneficiaries. The home health agencies then billed Medicare for the home health services they provided to the referred patients.

The Anti-Kickback Statute prohibits the provision of remuneration with the intent to induce referrals of government health care program business. The Anti-Kickback Statute is intended to ensure that medical providers’ judgments are not compromised by improper financial incentives. Claims that are knowingly submitted in violation of the Anti-Kickback Statute are ineligible for payment and can violate the False Claims Act.

“It is imperative to ensure that improper financial incentives play no role in decisions regarding patient care,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “Today’s resolution demonstrates the department’s commitment to protecting the integrity of federal health care programs and the medical treatment received by their beneficiaries.”

The Companies received credit under the department’s guidelines for taking disclosure, cooperation and remediation into account in False Claims Act cases. Among other actions, the Companies disclosed the conduct to the government, identified the individuals involved and assisted in the determination of losses caused to Medicare.

The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

Trial Attorney Elizabeth A. Strawn of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Brandi Stewart for the Southern District of Ohio handled the matter.

The claims resolved by the settlement are allegations only. And there has been no determination of liability.

Settlement

DOJ Announces Financial Incentives for Whistleblowers

by Elizabeth E. Hogue, Esq. | Mar 13, 2024 | Regulatory

by Elizabeth E. Hogue, Esq.,

DOJ Says “Knock on Our Door Before We Knock on Yours”

On March 7, 2024, the U.S. Department of Justice (DOJ) announced a new pilot program that includes financial incentives for whistleblowers to report violations. The new pilot program will be launched later this year following a process to develop and implement the pilot, which is expected to take ninety days.

The DOJ likens this new program to “the days of ‘Wanted’ posters across the Old West” in the sense that law enforcement has historically benefited by offering rewards for tips and information. When whistleblowers help the DOJ discover significant misconduct, they may benefit financially from monies recovered.

The goals of the pilot program are to:

Produce more evidence for successful white-collar criminal prosecutions
Impose more significant penalties on wrongdoers
Aid in prosecution of large-scale misconduct

Here are some details:

The core principle is that when individuals help DOJ identify significant misconduct that is otherwise unknown to DOJ, they may qualify to receive a portion of any resulting recoupments.
Payments to whistleblowers will be available only when:
- All victims are properly compensated before whistleblowers
- Whistleblowers provide truthful information
- Information provided by whistleblowers is not already known to the DOJ
- Whistleblowers are not involved in criminal activity
- No other relevant financial disclosure incentive exists

The DOJ says that it expects the pilot program to increase the likelihood that employees will decide to report misconduct to the DOJ without first notifying companies that employ them. This result will significantly decrease benefits to companies that decide to self-report because the benefits of self-reporting are available only when the government does not already know about the misconduct. This incentive may produce a race to the DOJ by employers and their employees reminiscent of races to the courthouse.

These incentives also underscore the importance of making it clear in Compliance Programs that employees and contractors are required to report alleged misconduct to their employers/partners first before they tell outside third-parties. Certain woe will come to companies that ignore these allegations or, God forbid, retaliate against potential whistleblowers!

The DOJ and other fraud enforcers are generally enamored with whistleblowers and the information they provide. They are perhaps even more enamored with encouraging companies to self-report.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Fraud and Abuse Compliance

Why All Providers Should Have One

Why should we have a Fraud and Abuse Compliance Program?

First

Next

Additionally

Also…

Finally

We don't receive reimbursement from the Medicare or Medicaid Programs.

Do we still need a Compliance Program?

Should we just use the model guidance that is applicable to us?

Do we have to conduct internal audits first?

We already have policies. Why do we need a Compliance Program too?

We're accredited. Doesn't that mean we are in compliance?

Will it help with investigations?

Final Thoughts

DOJ Settles with UnitedHealth and Amedisys

Judge to Weigh In

Public Comment Period and Judicial Review

Antitrust Division Statement

Divestiture Agreement

Not the Only Concern

Vertical Integration

Upcoding

Final Thoughts

Fraud, Waste, and Abuse

DOJ, HHS False Claims Act

Working Group

Working Group Priorities to Combat Fraud, Waste, and Abuse

Report Fraud, Waste, and Abuse

DOJ Rejects Plan to Divest Assets

Divesting Assets

This could spell T-R-O-U-B-L-E

Mediation

UnitedHealth, Amedisys to Divest Home Health & Hospice...Again

History

Anti Anti-Trust

BrightSpring

New Deal

No Deal Yet

Final Thoughts

UHG and Amedisys Waive Termination

DOJ Pushes Back

Merger Deadline Reached

Indefinite Merger Extension Through 2025

What If?

Justice Department Sues

Statement from the Department of Justice

UnitedHealth Group's Proposed Solution

Good News for Home Health and Hospice

Final Thoughts

False Claims Act Violations

Whistleblowers

Allegations

More Allegations

Settlement

Repeat Offender

Not Alone

Evolution Health LLC

Halo Home Healthcare

Atlantic Home Health Care

Speak Up, Speak Out

DOJ Says “Knock on Our Door Before We Knock on Yours”