Electronic Health Records

Healthcare fraud leads to enrollment moratoria in hot spots

Beginning July 30, new home health provider and supplier applications for enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) won’t receive the approval of the Centers for Medicare & Medicaid Services (CMS), according to a notice published in the Federal Register. Lasting six months, the temporary enrollment moratoria apply to three metropolitan areas that have been deemed healthcare fraud “hot spots.”

“CMS is using all available tools, including these moratoria, to combat fraud, waste and abuse in these vital health care programs,” said CMS Administrator Marilyn Tavenner in recent public statement.  “While maintaining patients’ access to care, we are putting would-be fraudsters on notice that we will find and stop them before they can attempt to bill Medicare, Medicaid and CHIP.”

In Miami (Miami-Dade and Monroe) and Chicago (Cook, DuPage, Kane, Lake, McHenry, and Will), newly-enrolling home health agencies (HHAs) will be denied approval. In Houston (Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Waller), newly-enrolling ground ambulance suppliers will suffer the same fate until the moratoria are lifted.

“It is important to note that all of the moratoria target areas identified in this notice — Miami, Houston, and Chicago — are Strike Force cities, and each of these areas has experienced intense, sustained criminal prosecution activity with respect to the provider and supplier types subject to these moratoria,” states CMS in the notice. “In addition, CMS’s own administrative investigations and oversight have been equally intense in these areas.”

A review of Medicare and Medicaid data by the Department of Health & Human Services (HHS) and the Office of Inspector General (OIG) and consultations with local law enforcement demonstrate higher-than-average home health agency practices in and around Miami and Chicago and ground ambulance suppliers in the metro-Houston area.

The notice issued on July 30 provides insight into why these three areas have been handed a temporary ban. For instance, there is the case in Miami-Dade County:

• The county has an average of 37.6 HHAs as compared to the national average of 1.8 HHAs per 10,000 Medicare FFS beneficiaries;

• The number of HHAs in the county has grown at twice the going rate, 15 percent versus the national average of 7 percent.;

• The average annual payments to Miami-Data HHAs were abnormally high, nearly double the national average, $10,287 and $5,783 per average Medicare home health user per year, respectively;

• Home health fraud cases in the county have led to 85 guilty pleas and 8 trial convictions;

• As recently as May 2013, an employer for a Miami healthcare company received a 37-month prison sentence for his involvement in a $20-million scheme to defraud Medicare.

The temporary enrollment moratoria will be in effect for six months after which time, CMS will determine whether to lift the ban or extend it in six-month increments. When lifted, providers and suppliers seeking to enroll in one of the three programs will be subject to high levels of screening during the six months following the ban being lifted.

To date, CMS has recouped more than $14.9 billion and the revoking of the ability of 14,663 providers and suppliers to bill Medicare as a result of its investigations into healthcare fraud.


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