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False Claims Act Violations in the Home Healthcare Industry

Home healthcare companies give home patient care by skilled professionals, such as: registered nurses; psychiatric nurses; physical, occupational and speech therapists; certified nursing assistants; and social workers. These companies, which provide personal care services (PCS) in the home, must follow specific Medicare and Medicaid rule and regulations in order to bill those government payors for the services rendered.

If they do not, they may be violating the False Claims Act and may be sued in a qui tam action for such violations.

One such rule requires 90 -day supervisory visits.  Specifically, Medicaid's Clinical Coverage Policy 3L, 7.10b: Supervisory Visits in Beneficiary Private Residences, requires the following:

The In-Home PCS Provider shall ensure that a qualified RN Nurse Supervisor conducts a RN Supervisor visit to each beneficiary's home location every 90 calendar days. Two visits within 365 days shall be conducted when the In-Home Aide is scheduled to be in the home. The RN Supervisor shall:

  1. Confirm that the In-Home Aide is present or has been present as scheduled during the preceding 90 days.
  2. Validate that the information documented on the aide's service log accurately reflects his or her attendance and the services provided.
  3. Evaluate the In-Home Aide's performance.
  4. Identify any changes in the beneficiary's condition and need for PCS that may require a change of status review.
  5. Request a change of status review if the beneficiary's plan of care exceeds or nolonger meets the beneficiary's needs for ADL assistance.
  6. Identify any new health or safety risks that may be present in the home.
  7. Evaluate the beneficiary's satisfaction with services provided by the In-Home Aide and the services performed by the home care agency.
  8. Document all components of the supervisory visits to include the date, arrival and departure time, purpose of visit, findings and supervisor's signature.
  9. Review and validate the in-home aide's service records to ensure that:
  • A. Documentation of services provided is accurate and complete;
  • B. Services listed in the plan of care have been implemented;
  • C. Deviations from the plan of care are documented;
  • D. Dates, times of service, and services provided are documented on a daily basis;
  • E. Separate logs are maintained for all beneficiaries;
  • F. All occasions when the beneficiary was not available to receive services or refused services for any reason are documented in the service record, including the reason the beneficiary was not available or refused services; and
  • G. Logs are signed by the In-Home Aide and the beneficiary after services are provided on a weekly basis

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These "Visiting Nurse" supervisory visits must be documented every 90 days by a qualified Registered Nurse and the documentation must attest that each of the requirements of Clinical Coverage Policy 3L 7.10b was fulfilled.  The immediate penalty for non-compliance with Clinical Coverage Policy 3L is the repayment of all funds to Medicaid/CAP for the entire 90 day service period for all services rendered without the required supervisory nurse oversight.

Thus, per DMA Clinical Coverage Policy 3L 7.10(b), an RN supervisory must "confirm that the In-Home Aide is present or has been present as scheduled during the preceding 90 days."  If this supervisory visit does not occur and isn't properly documented, then there has been no confirmation that the aide was present in the home during the 90 day period and provided services.  Without this required confirmation, the services allegedly rendered during the 90 day period have not been properly verified and may not be able to be bill to Medicaid.

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Contact Us

If you have discovered evidence of government fraud, contact an experienced False Claims Act attorney before blowing the whistle. You may be entitled to a substantial reward and the legal protections afforded to whistleblowers under state and federal laws. The attorneys of Berger & Montague are nationally recognized experts in Whistleblower/Qui Tam actions with over a decade of experience pursuing these complex fraud cases. For more information or to schedule your confidential consultation, use the form on this page or call us at 1-800-424-6690.

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For further reading:
Our Law Firm's Approach to False Claims and Whistleblower Cases
Whistleblower/Qui Tam Litigation Statistics and Trends
Seeking Qui Tam Lawyers/Attorneys
Does a Qui Tam Relator Need to Identify Specific False Claims Submitted to the Government?


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