Good afternoon, This course subject is not listed below HIA 370: HIM Compliance

Question

Good afternoon,

This course subject is not listed below HIA 370: HIM Compliance

I need assistance with the following below:

This week, we are going to discuss an actual example of a compliance fail. Read this report, then post your thoughts about what went wrong here.

Brooklyn-Based Home Health Care Service and Its President Agree to Pay Over $6.4 Million to Settle False Claims Act Suit Alleging Improper Billing Practices

Home Family Care, Inc. (HFC), a Brooklyn-based company that provides home health care services, and Alexander Kiselev, the co-owner and President of HFC, have entered into a civil settlement agreement under which they have agreed to pay $6,415,000 to resolve allegations that they violated the federal and state False Claims Acts by falsely billing Medicaid for home health care services that HFC did not provide to Medicaid recipients. HFC’s former Vice President, Michael Gurevich, entered into a separate settlement regarding the same allegations. The settlement agreements were approved by United States District Judge Sterling Johnson, Jr.

Richard P. Donoghue, United States Attorney for the Eastern District of New York, announced the settlements.

“When health care providers seek and receive Medicaid funds for services that they never provided, they jeopardize the fiscal integrity of a critical health care program,” stated United States Attorney Donoghue. “We will hold health care providers accountable for their violations of federal law.” Mr. Donoghue thanked the Medicaid Fraud Control Unit of the Office of the New York State Attorney General, the Office of the Inspector General of the U.S. Department of Health and Human Services, and the New York Office of Field Operations and the Office of Associate Chief Counsel (New York) of U.S. Customs and Border Protection for their assistance in the investigation.

An investigation revealed that, from the time HFC began operating in or about 2008 until at least May 2014, HFC engaged in a fraudulent scheme to enrich itself at the expense of Medicaid by knowingly and systematically billing for home health aide and personal care aid services that were not in fact provided to Medicaid recipients. To carry out this scheme, HFC directed its employees to deliberately circumvent its own system for verifying the attendance of aides at the homes of Medicaid recipients for whom the aides were allegedly providing care and to deliberately circumvent HFC’s internal controls that purported to ensure that aides were present in the recipients’ homes.

The allegations were brought to the government’s attention through the filing of a complaint pursuant to the qui tam provisions of the False Claims Act. Under the Act, private citizens can bring suit on behalf of the United States and share in any recovery.

Explanation / Answer

In this case, a Brooklyn-Based Health Care Service is found to be misusing the Medicaid clauses and showing false bills to claim Medicaid aids. The primary cause that led to this failure was the absence of a regulatory body that should have kept the sanctity of such claims in check. A regulatory body, must conduct random audit checks on such health care institutions and check if the compliances for several government policies like Medicaid are being maintained or not. The consequences of being caught, misleading facts and figures must also be very huge. The license of such health care institutions must be revoked apart from fining them for the Government aid loss. This consequence will keep such bodies from indulging in any kind of fraudulent activities or claims.

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