Amedisys, Inc. and its affiliates have agreed to pay $150 million to the federal government in order to settle allegations of fraud and misconduct. According to statements revealed earlier this month, the Department of Justice settled with the home healthcare and hospice provider after uncovering several years’ worth of improper bills and invoices for healthcare services.
In a statement, the United States Attorney for the Eastern District of Pennsylvania Zane David Memeger said:
“Combating Medicare fraud and overbilling is a priority for my office, other components of the Department of Justice, and United States Attorneys’ Offices across the country….We have recovered billions of dollars in federal health care funds from schemes such as the one alleged in this case. Those are health care dollars that should be spent on legitimate medical needs.”
The fraud case against Amedisys involves alleged violations of Medicare reimbursement rules, which clearly delineate the requirements a facility must follow with regard to invoicing for home healthcare services and hospice care. With regard to home healthcare, Medicare guidelines currently require applicants to meet four criteria:
- An applicant must be under the care of a doctor pursuant to an official Plan of Care;
- The doctor must certify that the applicant needs either intermittent skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy;
- The agency providing home health services must be approved by Medicare;
- The applicant must meet the definition of “homebound,” which means leaving the home is not recommended due to the patient’s condition. A homebound person is also unable to leave his home without the assistance of another person or apparatus, and leaving the home takes considerable physical effort.
Medicare guidelines also address eligibility criteria for those in need of hospice care. In order to properly qualify for reimbursement for hospice services, the beneficiary must meet all of the following criteria:
- Eligibility for Medicare Part A (hospital insurance);
- Both the applicant’s doctor and the director of the hospice facility agree that the applicant is terminally ill and likely to pass away within six months if the illness or injury runs its natural course;
- The applicant agrees to submit to hospice (non-curative) care as opposed to pursuing a curative form of treatment;
- The hospice program is approved by Medicare.
The federal False Claims Act applies in the event a medical facility or doctor knowingly submits an invoice for reimbursement covering a patient that should not have been approved for home healthcare or hospice. Individuals bringing a claim under the FCA’s whistleblower provisions may recover up to 30 percent of the government’s recovery.
Amedisys Fraud Case Details
In the case against Amedisys, Inc., whistleblowers are set to receive $26 million for coming forward with allegations of unlawful reimbursement for home healthcare and hospice services. Specifically, Amedisys allegedly billed Medicare for home health services covering patients who did not meet the above-described definition of “homebound.” Amedisys similarly billed for home health therapy services that were medically unnecessary, including physical therapy and nursing services that patients did not need.
More specifically, Amedisys implemented a program known as “Balanced for Life,” which allegedly involved ambiguous eligibility criteria allowing virtually any patient to qualify. The Balanced for Life program provided home-based geriatric care for purposes of correcting or managing “balance disorders” in the elderly. According to reports, Amedisys employees were required to initiate extra “bonus” home visits in order to trigger additional Medicare home therapy coverage.
In addition to its alleged misrepresentations of homebound clients, Amedisys, Inc. is further alleged to have misrepresented clients’ conditions in order to increase billable activity for Medicare patients. The fraud occurred between 2008 and 2010 and was reported by former employees of Amedisys, Inc.
Other allegations against Amedisys involve possible improper financial relationships between the company and a Georgia-area oncology center. According to the government investigation, Amedisys employees provided patient care “coordination services” to the oncology center at below market value. The DOJ also included details that members of Amedisys maintained improper relationships with oncology doctors by offering undisclosed incentives to oncologists willing to refer their patients to Amedisys for home healthcare services. This practice violates anti-kickback rules and a separate statute known as the Stark Law.
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