Don't Get Hammered!

I'm tempted to open this article by saying, “government scrutiny of the home care industry is at an all- time high.” All that stops me is that I've already said that each year for most of my 25-year legal career.

But I cannot deny that the feds are watching more carefully than I can remember their doing before, challenging claims more aggressively and targeting financial relationships involving home care companies more frequently.

Lincare just negotiated a $12 million settlement with the feds for allegations of bogus contracts with physicians, supposedly paying for unnecessary or phantom services in order to disguise a supposed payment for referrals. At much smaller levels, I am noticing a disturbing tendency for claims reviewers in the DMERCs' fraud units to characterize imperfect or questionable claims as “fraudulent” with very little evidence to back up such an incendiary contention.

At the same time, I see too many HME providers with dangerous gaps in their knowledge and appreciation of the anti-fraud rules. Small companies are getting hit just as hard and frequently as are bigger companies.

Ignorance is not bliss. It is a disease, which sooner or later will consume your business. This is not just hyperbole on my part. I have had the sad task of attending to the closure of a number of clients, all of whom were unaware of the practical dangers of indifference or carelessness about embracing these rules.

With that in mind, here are answers to the most frequently asked questions about the anti-fraud rules — and why you should care.

Question: What are these anti-fraud rules all about, and why should I care?

Answer: Anti-fraud rules come from a wide range of federal laws. These include the Anti-Kickback Statute, which prohibits any health care provider from giving or receiving anything of value in exchange for referring or receiving referrals of patients, goods or services related to government-funded programs.

There is also the Stark Law, which prohibits physicians from receiving financial benefit from any provider of “designated health services” (including home medical equipment providers) to whom the physician refers Medicare or Medicaid business, unless the relationship or the referral falls into one of the law's exceptions.