This Moment in Corrution: Yet Another Misbehaving Home Health Agency

In the latest announcement (Aug. 15) from Attorney General Maura Healey concerning the work of her department's Medicaid Fraud Division, we learn that a Boston-based home health company, Guardian Healthcare, will be paying $1.95 million "to resolve allegations that it filed claims for payment...that were not certified as medically necessary."

From April 2010 through July 2016, the AG's office said, Guardian "failed to obtain and/or maintain plans of care authorized by a physician for certain patients."

In order for a home health agency to bill MassHealth (the name we give to Medicaid in Massachusetts), a MassHealth patient's physician must review and sign a plan of care certifying that home health services are medically necessary.  Further, home health agencies are required to maintain good records for at least six years after care has been provided and claims for payment have been made.

In addition to laying nearly $2 million on the Commonwealth of Massachusetts, Guardian has agreed to implement "a multi-year, independent compliance program which will involve updating its policies and procedures, training its staff, and conducting annual audits to ensure compliance with federal and state regulations."

The AG's office said the Guardian settlement "is part of a larger effort to combat fraud in the home health program," and cited these other cases:

• The conviction of the owner of a home health company in May on charges related to fraudulent billing to the tune of $2.5 million.
• The payment in April of more than $10 million by two home health companies to resolve allegations of billing for unauthorized services.
• The conviction of the owner of a Boston home health company in August of 2018 on charges stemming from a scheme "to steal millions from MassHealth."

At roughly $17 billion in total spending, MassHealth will account for more than 40 percent of the entire state budget during the current fiscal year, 2020.  (It's important to note that the federal government will reimburse the state for more than half of all that spending.)  The program covers 1.8 million Massachusetts residents, one in every four.

The latest available figures indicate that, in FY 2018, Healey's Medicaid Fraud Division recovered over $45 million for MassHealth.

Spending tax proceeds on the Medicaid Fraud Division is a good investment.  For every dollar earmarked by the legislature for this purpose in FY 18, the Division recovered $11 from the program's bad actors.