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healthcare defense defending home health fraud the 5 pitfalls of home health care lawyers

June 30, 2020

Home health fraud is a major problem for many companies that provide specialist care in the homes of their patients. Home healthcare has always been a difficult area for defense lawyers looking to protect their clients from prosecution because of the nature of the work being done outside the traditional medical facility. In general, the success of the defense for those accused of home health fraud comes down to excellent record keeping and a complete understanding of the ins and outs of Medicare fraud.

What is Home Health Fraud?

The first thing to understand is exactly what is meant by home health, which is the provision of healthcare to those who cannot leave their homes for prolonged periods. Among the services that can be offered to patients under the home health mantle are those of physical therapy, skilled nursing, and hospice services. The majority of Medicare and home healthcare fraud cases take the form of incorrect procedures being followed by the nursing company before and during their home healthcare work. A high-quality defense lawyer will help a company understand exactly how they have fallen foul of the Department of Justice whether they have meant to deceive or not.

1. Does a Patient Qualify?

This is the main question that needs to be answered when a home healthcare provider is making the decision to provide services for a patient at home. The signing of Medicare Form 485 is a legally binding federal document that must be certified by a physician who ensures the patient is affected by a long-term condition that makes them homebound.

Many of those who are affected by Medicare fraud investigations are those who may have misunderstood the requirements for a patient to be classified as homebound. Medical conditions such as hypertension and obesity can form the basis of qualification but they are not enough to completely qualify for home healthcare services.

2. Marketing Requirements

Federal rules and regulations can be difficult to understand and navigate with the use of marketing materials and companies a difficult question to answer. It is not permitted under federal regulations to pay marketing professionals under certain payment structures. A home healthcare fraud investigation can begin purely because a marketing specialist was employed and paid using a 1099 tax form instead of a W-2.

Every aspect of the work done by a home healthcare provider paid for by Medicare funds should be transparent, meaning a verbal or non-written contract can cause issues. In some cases, the anti-kickback statutes that are in place can be violated simply by not providing the correct employment contract to a marketer.

3. Maintaining the Correct Medical Director Status

A medical director sits in a specific role that should never overstep into the realm of the physician and patients sector. The supervisory nature of the work completed by the Medical Director often pushes into the work of physicians which breaks the rules of the Federal Government when it comes to Medicare funds. Medical Directors are limited to their role as signers of certifications and recertifications and checking the requirements of Medicare are constantly met with any extra work pushing the company towards prosecution by the Department of Justice.

4. Upcoding and Billing Issues

Among the most common issues facing home healthcare agencies are those of upcoding and billing mistakes during their everyday activities. Upcoding is the process of inputting the incorrect codes when recording which services have been provided by any member of staff. The upcoming issue has come to light when federal prosecutors investigate a range of home healthcare agencies for fraud problems. Billing issues can include a member of staff recording the wrong time for their time spent working with a patient or giving details of the wrong services provided.

5. The Onus is on the Agency

It can be difficult for a home healthcare agency to ensure they keep track of every record held by their company to ensure it is correct. In the majority of cases, the onus is placed firmly on the company to make sure they are consistently on the right side of federal law.

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