RISE summarizes recent regulatory-related headlines.
DOJ: NURSE PRACTITIONER PLEADS GUILTY TO $7.8M TELEMEDICINE FRAUD SCHEME
A Virginia-based nurse practitioner pleaded guilty Monday in federal court in Boston in connection with a $7.8 million telemedicine fraud scheme involving medically unnecessary durable medical equipment (DME), including orthotics such as back and knee braces.
Daphne Jenkins, 64, pleaded guilty to one count of conspiracy to commit health care fraud. According to the Department of Justice, between December 2018 and April 2020, Jenkins worked with a telemedicine company to sign orders for medically unnecessary durable medical equipment. These orders signed by Jenkins were pre-populated based on telemarketing calls made to Medicare beneficiaries. Jenkins never had any contact with the beneficiaries herself and had no medical relationship with the beneficiaries, and she generally signed these orders without even reading them. Once Jenkins signed these orders, the telemarketing company sold the orders to DME suppliers and laboratories, which then submitted claims to Medicare.
As a result, more than $7.8 million in claims were submitted to Medicare for DME that was medically unnecessary, based on false documentation, and tainted by kickbacks.
The charge of conspiracy to commit health care fraud provides for a sentence of up to 10 years in prison, up to three years of supervised release, and a fine of up to $250,000 or twice the gross pecuniary gain or loss, whichever is greater. Jenkins’ sentencing is scheduled for April 10, 2024.
OIG AUDIT FINDS SELECTCARE RECEIVED $5.1M IN OVERPAYMENTS FOR 2015 AND 2016
A recent audit by the Office of Inspector General (OIG) reveals that SelectCare of Texas, Inc., a Medicare Advantage organization, received $5.1 million in net overpayments from Medicare for claims of high-risk diagnosis codes that didn’t comply with the Centers for Medicare & Medicaid Services’ risk adjustment program.
Auditors sampled 285 unique enrollee-years and reviewed portions of the payments for 2015 and 2016 associated with high-risk diagnosis codes totaling nearly $690,000. They found that the diagnosis codes for 220 of the 285 sampled enrollee-years were not supported in the medical record or couldn’t be supported because SelectCare couldn’t locate the medical records. The result was $482,601 in net overpayments. Based on the sample results, OIG estimates the organization was overpaid by $5.1 million.
OIG recommends that SelectCare refund the federal government the $482,601 in net overpayments, identify similar instances of noncompliance that occurred before or after the audit period and refund any resulting overpayments, and review and make improvements to its existing compliance procedures.
KFF: MAJORITY OF STATES HAVE WAITING LISTS FOR SOME MEDICAID HOME CARE PROGRAM
A new KFF analysis of survey data from state Medicaid home care programs found that since 2016, there have been nearly 700,000 people on waiting or interest lists for expanded home and community-based services, with a total of 692,000 across 38 states in 2023 and waiting lists averaging three years.
People with intellectual or developmental disabilities make up almost three-quarters of waiting lists, with seniors and adults with physical disabilities constituting another quarter. People on waiting lists may not have access to increased hours of home care to support activities such as bathing, dressing, preparing meals and managing medication as well as increased types of community care, such as adult day care and supported employment, which are often designed to meet the needs of specific populations.
States can cap enrollment for these services, resulting in waiting lists (also described as “interest lists”) for expanded home care programs when demand surpasses the available slots. While these lists are an imperfect measure of unmet need, there are currently no alternative measures.
Home care waivers that allow states to offer these services have been in place since the 1980s, but their use increased after the Supreme Court’s Olmstead decision in 1999, which characterized the unjustified institutionalization of people with disabilities as illegal discrimination. As the 25th anniversary of Olmstead nears, people have cited waiting lists as one reason for continued discrimination based on disability.
Shortages of home care workers could worsen states’ waiting list times. Although states reported increasing provider payment rates and other efforts to bolster the workforce, challenges remain and some state policies for addressing these challenges ended with the conclusion of pandemic-era programs.
Another factor affecting waiting list volumes is whether states screen for Medicaid eligibility before adding people to waiting lists. Between 2018 and 2020, waitlist sizes for expanded home care programs fell by 19 percent nationally, largely due to eligibility assessments added to waiting lists. Today, all but six states screen their waiting lists for Medicaid eligibility.
Rules proposed earlier this year would require states to report the size of their waiting lists.
COMMONWEALTH FUND EXPLORES IMPLICATIONS OF MEDICAID UNWINDING CRISIS
Amid rushed Medicaid eligibility recertification in certain states as part of the unwinding of Medicaid’s pandemic-related continuous enrollment guarantee, millions of Americans are losing their coverage for procedural reasons, even though they are still eligible, according to a new issue brief published by Commonwealth Fund.
Researchers from the Milken Institute School of Public Health at the George Washington University write that more than 70 percent of those disenrolled lost coverage due for procedural reasons, such as failure to return forms or inaccurate mailing address or an agency error. Meanwhile, there is anecdotal evidence that those terminated for procedural reasons are being turned away from the health insurance marketplace because states close cases without determining if beneficiaries are truly ineligible for Medicaid.
The federal government has started to take action to mitigate erroneous coverage loss, urging states to guard against without an individualized ex parte review and also ordered reinstatement of a half-million children and adults disenrolled simply because other family members were no longer eligible. The agency has ordered states to halt disenrollment until corrective action is taken.
“The current unwinding situation presents a unique challenge for states, health care providers, and above all, millions of beneficiaries who depend on Medicaid,” researchers wrote. “It is important to remember that continuous enrollment enacted during the pandemic was a response to three structural limitations that are part of everyday Medicaid: first, highly restrictive eligibility limits, particularly in states that do not cover low-income working-age adults; second, the lack of annual guaranteed enrollment for all beneficiaries, regardless of age or basis of eligibility; and third, a redetermination process that, despite improvements, continues to face enormous operational challenges.”