In yet another instance of costly and wasteful healthcare fraud, CareAll Management, LLC has agreed to pay $25 million to resolve allegations of illegal upcoding and falsification of information on official requests for reimbursement. In the context of healthcare fraud, the False Claims Act is triggered whenever an invoice is submitted for repayment on behalf of Medicare or Medicaid patients and that invoice contains intentionally false information. The False Claims Act, which has been around since the 1800’s, has proven especially helpful in recent years as over $23 billion has been recovered on behalf of federal healthcare programs. Many states have enacted legislation similar to the federal False Claims Act, allowing state authorities to pursue fraud against the state-run portion of the Medicaid program and other state-level benefits agencies.
Details of United States ex rel. Gonzales v. J.W. Carell Enterprises, Inc.
CareAll Management, LLC is a Tennessee-based company and provides home-based healthcare services to those in need of care. Home-based healthcare is only covered under Medicare or Medicaid if certain criteria are met, including:
- Certification that the patient is under the care of a doctor and a specific care plan;
- Doctor-certification that the patient needs one of the following: (i) intermittent skilled nursing care; (ii) physical therapy; (iii) speech-language pathology services; or, (iv) continued occupational therapy;
- The home healthcare agency must be an approved provider by Medicare;
- The patient must be certified as “homebound,” which means the patient suffers from a condition where leaving the home is not recommended or is impossible.
According to allegations, Careall routinely certified patients as meeting these criteria when, in fact, these factors were not all present in each patient. Nonetheless, Careall continued to bill Medicare and Medicaid for homebound services when the patients were not in need of such individual care, were not actually homebound, or did not suffer from a medical condition as severe as was documented.
Apparently, according to federal authorities, fraud in home-based healthcare is “surging” across the United States, and has become a recent focus area for the H.E.A.T. Task Force – a group convened to systematically identify and prosecute healthcare fraud.
The $25 million settlement remitted by CareAll is to be shared by the State of Tennessee, and the whistleblower is set to receive $3.9 million. This is also not CareAll’s first False Claims Act settlement, and it is now under an enhanced corporate integrity agreement.
According to Special Agent in Charge Derrick L. Jackson of HHS-OIG Atlanta, “Fraudulent home-based services are surging across the country….We will continue to protect both Medicare and taxpayers, and ensure that funds are not siphoned off by companies more concerned with the bottom line than patient care.”
A U.S. Attorney for the Middle District of Tennessee also remarked, “This case demonstrates that enforcement of the False Claims Act is a priority of the U.S. Attorney’s Office for the Middle District of Tennessee….The U.S. Attorney’s Office and our law enforcement partners are committed to protecting the public and vigorously pursuing all those who knowingly submit false claims affecting the Medicare and Medicaid programs.”
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