Revocation of Home Health Agency's Medicare Enrollment and Billing Privileges Upheld

The revocation of a home health agency's (HHA) Medicare enrollment and billing privileges was recently upheld by an Administrative Law Judge in the Civil Remedies Division of the Health & Human Services Departmental Appeals Board (ALJ). The ALJ determined that the HHA was not in compliance with Medicare program requirements for home health care certification and therefore, the Centers for Medicare & Medicaid Services (CMS) had a legitimate basis to revoke the HHAs enrollment and billing privileges and impose a three-year re-enrollment bar. The case is CJN Enterprises, Inc. v. Centers for Medicare & Medicaid Services.

When HHAs enroll in Medicare, they must certify that they will abide by the Medicare laws, regulations and program instructions; and acknowledge that they will not knowingly submit false claims or submit claims with deliberate ignorance or reckless disregard for their truth or falsity. Payment of claims by Medicare is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions.

Among other requirements, Medicare will only make a payment to a HHA for home health services after the HHA obtains a valid certification from a physician stating that the patient is homebound and needs skilled nursing care.

In this case, CMS argued that the HHA submitted Medicare claims lacking a valid certification from a physician, and doing so constituted noncompliance. The ALJ agreed and determined that the HHA filed Medicare reimbursement claims containing improper physician certifications for at least four beneficiaries.

The physician whose name was on eight certifications submitted by the HHA signed an attestation stating that she did not actually treat all of those patients. The HHA owner testified that of the eight patients for whom they claimed payment, the certifying physician actually treated only four of them. A nurse employed by the HHA testified that the other four patients were seen by a different physician.

The ALJ determined that for at least four Medicare beneficiaries for whom the HHA claimed payment, the physician whose name was on the claim was not the treating physician or involved in their care or monitoring and thus could not be the certifying physician. Accordingly, the HHA was found not in compliance with the Medicare requirements.

The ALJ also determined that the HHA could not avoid the penalty by assigning blame to a third party biller. The HHA claimed that the third party biller hired by the HHA billed under the wrong provider identification number and made errors in the billing by confusing some of the other doctors and patients. The ALJ noted that it is the HHA's responsibility to ensure that they bill appropriately and there are no exceptions for claims prepared and submitted by billing agents.

The ALJ went on to say that HHAs must acknowledge that they will not knowingly submit false claims or submit claims with deliberate ignorance or reckless disregard for their truth or falsity when they enroll for participation in Medicare. By relying on the billing agent, the HHA failed to assure that its claims were properly submitted and therefore submitted claims with reckless disregard for the truth or falsity of the physician certification.

In sum, the fact that the HHA submitted invalid claims due to invalid physician certifications for four Medicare beneficiaries, whether or not due to its billing agent's error, supported the revocation of the HHA's enrollment and billing privileges.

If you have questions about this case or the Medicare participation requirements for home health agencies, please call Attorney Jillian Jagling at 401.824.5100 or email jjagling@pldolaw.com. We welcome your comments, questions and suggestions.

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