Medicare: Allegations Against ABC Home Health Care (Letter Report,
07/19/95, GAO/OSI-95-17).
In response to a congressional request, GAO investigated allegations
against ABC Home Health Care, a home health agency (HHA), and its
participation in the Medicare home health care program. In the Medicare
program, providers may receive reimbursement only for those expenses
that are reasonable in amount and related to patient care for eligible
patients. Current and former employees told GAO that local ABC officer
managers directed them to alter records to make it appear that patients
continued to need home health visits. Additionally, managers directed
employees to continue visiting patients who, in the employees' opinion,
did not qualify for home health care because they no longer met Medicare
rules defining homebound status. ABC also reportedly charged Medicare
for the cost of acquiring other HHAs by paying owners a small sum up
front and the balance in the form of salary under employment agreements,
a practice that is inconsistent with Medicare regulations for
reimbursement. Finally, according to former employees, some managers
directed employees to market ABC and its services with the intent of
charging Medicare for costs that is not reimbursable. GAO has shared
information concerning possible illegal activities with appropriate law
enforcement authorities. GAO summarized this report in testimony before
Congress; see: Medicare: Allegations Against ABC Home Health Care, by
Richard C, Stiener, Director, Office of Special Investigations, before
the Subcommittee on Health and Environment and the Subcommittee on
Oversight and Investigations, House Commerce Committee. GAO/T-OSI-95-18,
July 19 (eight pages).
--------------------------- Indexing Terms -----------------------------
REPORTNUM: OSI-95-17
TITLE: Medicare: Allegations Against ABC Home Health Care
DATE: 07/19/95
SUBJECT: Home health care services
Medical records
Patient care services
Fraud
Questionable payments
Program abuses
Medical expense claims
Forgery
Health care personnel
IDENTIFIER: Medicare Home Health Care Program
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Cover
================================================================ COVER
Report to the Ranking Minority Member, Committee on Commerce, House
of Representatives
July 1995
MEDICARE - ALLEGATIONS AGAINST ABC
HOME HEALTH CARE
GAO/OSI-95-17
ABC Home Health Care
(600335)
Abbreviations
=============================================================== ABBREV
CEO - Chief Executive Officer
CFMD - Coordinator of Field Management Development
GAO - x
HCFA - Health Care Financing Administration
HEHS - x
HHA - home health agency
HRD - x
NSIAD - x
OIG - Office of the Inspector General
OSI - x
Letter
=============================================================== LETTER
B-261406
July 19, 1995
The Honorable John D. Dingell
Ranking Minority Member
Committee on Commerce
House of Representatives
Dear Mr. Dingell:
This letter responds to your request that we investigate specific
allegations regarding ABC Home Health Care's (now known as First
American Health Care) participation in the Medicare home health care
program. Specifically, the allegations were that (1) ABC employees
altered or forged medical records to ensure continued or prolonged
home health care visits; (2) ABC employees made more visits to
patients than were necessary; and (3) ABC charged Medicare for costs
not related to patient care. This report discusses our findings on
each of these allegations. You subsequently asked that we review
ABC's cost reports regarding legal expenses for appealing denied
claims. As agreed, this issue will be addressed in separate
correspondence.
BACKGROUND
------------------------------------------------------------ Letter :1
The Health Care Financing Administration (HCFA)--an agency of the
Department of Health and Human Services--administers the Medicare
home health care program. The home health care program has been part
of Medicare since it began in 1965 and serves as an alternative to
lengthy inpatient hospitalization. To be eligible, patients, except
when receiving outpatient services, must be confined to their home
(i.e., "homebound") as certified by their doctor. Among the services
that patients receive in the home health services are (1) part-time
or intermittent skilled nursing care; (2) physical, speech, and
occupational therapy; (3) home health aide services as an adjunct to
skilled nursing or therapy care; (4) medical social services; and (5)
medical equipment and supplies. These services can be provided by a
Medicare-certified home health agency (HHA) or by others under
contractual arrangement with such an agency. ABC is one of some
8,100 Medicare-certified HHAs.
ABC is the largest privately held home health care provider in the
United States, and Medicare reimbursement represents approximately 95
percent of its total revenues. ABC is headquartered in Brunswick,
Georgia. Robert "Jack" Mills has led ABC since 1978 and is its
current Chairman and Chief Executive Officer (CEO). In the last few
years, ABC had grown rapidly. In 1990, ABC had 141 local offices in
10 states. It had 21,431 patients, performed almost 1.3 million
visits, and had Medicare revenues of $83.5 million. At the end of
1994, ABC had 354 offices in 21 states, made 7.8 million visits to
58,330 patients, and had Medicare revenues totaling $615.9 million.
In February 1995, the Office of the Inspector General (OIG), U.S.
Department of Health and Human Services, sent ABC an exclusion
letter, seeking to exclude it from participation in the Medicare
program for 7 years. (See app. I for a copy of the letter.) The
letter charged, in part, that ABC had submitted false or fraudulent
charges to the Medicare program for patient-related services
allegedly rendered during the course of 3 fiscal years--1987, 1988,
and 1992. Among the improper charges, the letter listed a number of
items that were acquired "solely for the personal use or enjoyment of
the Mills family," e.g., condominium utility expenses, maid services,
and automobile lease payments. The Inspector General charged that
ABC knew or should have known that these costs were not related to
patient care as required by federal law and regulations and that,
therefore, they should not be reimbursed. ABC has appealed the
proposed exclusion letter; an administrative hearing is pending.
We have shared information concerning possible illegal activities
with appropriate law enforcement authorities. Some of these
activities are under investigation. We discussed the nature of the
allegations that we investigated with ABC's CEO, Mr. Mills, and the
principal attorney for ABC. They replied that ABC has not knowingly
violated Medicare law or regulations. They added that the
regulations are vague and subject to broad interpretation and
selective enforcement. As reported previously by GAO,\1 a lack of
specificity and ambiguity in HCFA guidelines could invite
exploitation of the Medicare system.
--------------------
\1 Medicare: Need to Strengthen Home Health Care Payment Controls
and Address Unmet Needs (GAO/HRD-87-9, Dec. 2, 1986) and Medicare:
Better Guidance Is Needed to Preclude Inappropriate General and
Administrative Charges (GAO/NSIAD-94-13, Oct. 15, 1993). A GAO
report on another HCFA program has a similar finding--Medicare:
Tighter Rules Needed to Curtail Overcharges for Therapy in Nursing
Homes (GAO/HEHS-95-23, Mar. 30, 1995).
RESULTS IN BRIEF
------------------------------------------------------------ Letter :2
In the Medicare program, providers may receive reimbursement only for
those expenses that are reasonable in amount and related to patient
care for eligible patients. Current and former employees told us
that local ABC office managers directed them to alter records to make
it appear that patients continued to need home health visits.
Additionally, managers directed employees to continue visiting
patients who, in the employees' opinion, did not qualify for home
health care because they no longer met Medicare rules defining
homebound status. ABC also reportedly charged Medicare for the cost
of acquiring other HHAs by paying owners a small sum up front and the
balance in the form of salary under employment agreements. HCFA
officials and the Medicare fiscal intermediary\2 believe that this
practice is inconsistent with Medicare regulations for reimbursement.
Finally, according to former employees, some managers directed
employees to market ABC and its services with the intent of charging
Medicare for costs that HCFA does not reimburse.
--------------------
\2 A fiscal intermediary is a private contractor that processes
claims and audits HHAs on behalf of HCFA.
ABC MODIFIED MEDICAL RECORDS TO
CONTINUE TO PROVIDE SERVICES TO
PATIENTS WHO MAY BE INELIGIBLE
------------------------------------------------------------ Letter :3
Current and former ABC employees told us that medical records were
altered and forged to ensure continued or prolonged home health care
visits. We found instances in which ABC's records appeared to
justify home visits, but the patient seemed no longer eligible.
Medicare patients qualify for visits if they are confined to their
home (except when receiving outpatient services), under the care of a
physician who approves a plan of home care, and are in need of
intermittent skilled nursing care or physical or speech therapy.\3
Neither Medicare law nor regulations establish a ceiling on the
number of visits a patient may receive.
Physicians certify the initial need for home health services and
recertify the need for continued services at least every 2 months.\4
However, physicians are generally not required to see patients to
recertify continued need for home health visits. We found that
physicians typically rely on nurses' verbal and/or written
recommendations, which are part of the patient's records. In this
regard, nurses and aides are required to make notes for the services
they performed during each patient visit.
At 10 locations, according to current and former employees, ABC
office managers directed staff to alter nursing notes so that they
would not reflect indications of patient improvement. This practice
was intended to create the appearance that continued home health
visits were needed. In one office, a manager highlighted nurses'
notes that the manager wanted changed to make it appear that
continued care was necessary and dictated what the rewritten language
should be. After one nurse declined to describe the conditions of
her patients inaccurately, the manager asked another nurse to change
nursing notes although she had not seen these patients. Another
office manager directed a nurse to record visits that were never
made. That manager also forged physicians' signatures on plans of
care that described the treatment. In another instance, a local ABC
Quality Assurance Coordinator traced physicians' signatures onto a
physician recertification form. In another office, after plans of
care were signed by physicians, nurses added language that increased
the number of visits, without consulting with the physicians.
Several former ABC nurses and aides said that local ABC managers
stressed "negative charting." Under this concept, they were
encouraged to include only the negative aspects of a patient's
condition and to ignore any improvements. This strategy, therefore,
highlighted the appearance of the need for the continued care of
patients who were purportedly confined to the home. Nurses and aides
provided the following examples of negative charting.
In one instance, a diabetic home health care patient walked to church
regularly without assistance, but a manager directed the patient's
nurse to omit any reference to this fact. Another patient had had an
accident, lacerating a hand, while he was driving; however, a manager
told the nurse to change the cause of the injury to a fall as a
result of "a dizzy spell" to reflect the patient's need for continued
home care. Another patient never used a cane; however, a nurse was
asked to record that the patient required the use of a cane.
In other cases, patient records simply reflected that the patients
continued to be homebound. The patients continued to receive visits,
according to current and former ABC nurses, even after they were no
longer confined to their homes. For example, we visited one such
patient who routinely drove a vehicle to go grocery shopping.
Another patient usually walked alone once a day to eat at the local
senior citizens' center a few blocks away.
--------------------
\3 42 C.F.R. 424.22.
\4 42 C.F.R. 424.22(b).
ABC MANAGERS EMPHASIZED NEED TO
MAXIMIZE PATIENT VISITS
------------------------------------------------------------ Letter :4
Industry officials and current and former ABC employees told us that,
for those patients who were eligible for home health care, ABC
visited patients more frequently than did other HHAs. According to
these individuals, such frequent visits occurred partially because
ABC managers emphasized the need to increase patient visits. Each
month the corporation sent out what it termed "High Rollers Memos"
that congratulated those offices with the largest number of visits
for that month. Employees stated that the primary purpose of the
memorandums was to promote an increase in patient visits and Medicare
reimbursements.
A former manager told us that a senior manager had told local
administrators, "Increase the number of visits. Whatever it takes to
get that done, do it." Nurses and aides told us they felt pressured
to prolong treatment or to make more frequent visits. In their
opinion, they made frequent visits in order to keep the patient visit
count high. When they expressed their concerns to management about
visiting patients who did not qualify for home visits, they were told
by managers either to continue with the visits or to reduce the
frequency of visits to the patients. According to nurses and aides,
managers were more likely to decrease the visit frequency for
patients no longer eligible for home care rather than to discontinue
visits altogether.
We found that some patients and their families complained that ABC
visited too often. In Florida, for example, the family of a patient
complained that ABC nurses continued to come to their home despite
their objections. On some days, the family would complete a certain
task that the nurse or aide was scheduled to do before the individual
arrived at the home; therefore, for that day, a visit would not be
needed. Nevertheless, the nurse or aide would ask the family to sign
a form so that they could get paid for the task that they were
scheduled to perform. Similarly, in Pennsylvania, a former ABC nurse
recalled that a patient questioned her as to why she was being seen.
The nurse acknowledged that, in her opinion, the woman did not
require home care.
In various locations, former employees told us that office managers
directed nurses and home health aides to visit new patients for a
specified number of consecutive days regardless of their condition.
For example, some employees told us that managers told nurses to
visit new patients the first 5 days regardless of condition, while
other employees stated that ABC stressed visiting new patients daily
for the first 14 or 21 days of care regardless of condition.
Generally, HCFA will not question daily visits during the first 21
days of care.
ABC REPORTEDLY CHARGED MEDICARE
FOR COSTS OF PURCHASING HOME
HEALTH AGENCIES AND FOR GIFTS
GIVEN TO PHYSICIANS
------------------------------------------------------------ Letter :5
ABC reportedly charged Medicare for questionable costs when ABC
included expenses associated with the purchase of other HHAs in its
cost reports. Allowable costs of an acquisition are primarily
depreciation, over a period of years, of the value of the business
assets acquired and interest expense for necessary borrowing related
to acquiring those assets. Typically, HHAs own a limited number of
assets, such as office furniture, equipment, and leases. We found
that this was true for those ABC acquisitions that we reviewed.
Therefore, the amount that ABC could reasonably include in its
Medicare cost reports would be minimal. According to former
corporate officials and owners we interviewed, ABC would pay owners a
small amount to cover asset values and enter into an employment
agreement with the owners to cover the remainder of the purchase
price. In some cases, former owners worked for their salaries; in
other instances, they performed minimal work or no work for their
salaries. Additionally, former employees told us that, with the
intent of obtaining Medicare reimbursement, ABC managers directed
employees to incur "educational" expenses that were actually gifts
made to physicians in return for patient referrals.
EMPLOYMENT AGREEMENTS WITH
FORMER HHA OWNERS TO FUND
AGENCY PURCHASES
---------------------------------------------------------- Letter :5.1
HCFA officials and the Medicare fiscal intermediary do not view ABC's
reported method for charging Medicare for the overall purchase price
of other HHAs as appropriate. Former owners who had sold their HHAs
to ABC maintain that ABC masked the total price of purchasing their
HHAs by paying HHA owners a small sum up front and the balance in the
form of salary under employment agreements over a number of years.
As a result, former owners and former managers concluded that ABC had
charged most of the purchase price to Medicare by claiming that the
salary paid under the employment agreements was not for the HHA
acquisition price but for work performed by the former owners.
Since the late 1980s, at least 20 former home health care agency
owners signed employment agreements with ABC. The terms of the
employment agreements stated that the former owners would devote
their "working time to the affairs of the company," as specified, and
report directly to
Mr. Mills. One of the seven former owners that we contacted stated
that she had signed the employment agreement with the understanding
that she would perform no work for ABC. The other six indicated that
when they signed the agreements, they understood that ABC was
expecting them to work under the terms of the employment agreement.
However, in these seven cases, ABC gave the former owners minimal
duties and/or prohibited them from entering the office to do any
work, although they continued to draw a salary. Additionally, ABC
later terminated these employment agreements and removed the former
owners from the payroll before their agreements expired, alleging
that the former owners had failed to fulfill the terms of their
agreements. After they had been prohibited from working, these
former owners questioned whether the employment agreements were
merely a way for ABC to have Medicare unknowingly pay for the HHA
purchase price.
One former owner signed a 5-year employment contract that specified
that his duties would be limited to part-time community affairs.
There was no purchase price for his agency; however, ABC paid him
$12,000 for used furniture, signed a 5-year lease for his building,
and provided him with a 5-year employment contract at $35,000 a year
plus fringe benefits with a salary escalator clause. However, he
told us that he worked less than 1 month a year under his employment
contract because he was occupied with his other businesses and ABC
did not want him to interfere with its operation. A former ABC
manager told us that when other employees told Mr. Mills that this
former owner was trying to help run the HHA, Mr. Mills asked, "Why
doesn't he just stay home?" When this former owner learned that ABC
was charging his salary to Medicare, he became concerned that he
might be targeted for fraud because of his minimal work. He told us
that he then negotiated a buyout slightly over 2 years into the
employment agreement. According to ABC's attorney, ABC negotiated
the buyout because the former owner had refused to report to a female
supervisor.
A second former owner entered into an employment agreement with ABC
for 5 years with an automatic extension for another 5 years at a
salary rate of $50,000 per year. Although he was supposed to do
community affairs work under the terms of his agreement, he
acknowledged that he did so only a few hours a day. In addition to
the work he performed for ABC for more than 5 years, he ran another
business and had a part-time position elsewhere. He stated that his
employment agreement also provided for a bonus if he increased the
number of patients for ABC. He indicated that after receiving a
bonus at the conclusion of the first year of his agreement, Mr.
Mills told him that Medicare would not pay for bonuses in the future.
According to ABC's attorney, ABC released the former owner because he
had declined to give up a part-time position outside ABC.
A third former owner signed an employment agreement which stated that
she would receive $10,000 per month for 5 years. The former owner,
who understood that there would be no work required of her, said Mr.
Mills told her she could spend her time tending to her garden and her
antiques. During the 23-month period in which she remained on the
payroll, she did not perform any work but received her full salary.
ABC subsequently terminated her employment, citing her inability to
perform any work. A former ABC corporate official stated that he
believed she had sold her business in good faith to Mr. Mills with
the understanding that there would be very little "up front" money
and that the salary stipulated in the employment agreement was her
form of reimbursement for the buyout of the business. When the
former official objected to the generous salary provided to the
former owner for doing no work, the former official quoted Mr. Mills
as replying, "You just don't understand. I am paying her for the
purchase price of her agency through the employment contract."
In another instance, a physician entered into a contract with ABC for
the purchase of his HHA. Terms of the agreement provided for hiring
the physician as a consultant at a fee of $5,000 per month for a
6-month period. Despite the physician's objections, Mr. Mills
prohibited the physician from performing any kind of active role in
the operation of the business once the sale had been consummated and
did not pay him anything. According to ABC's attorney, this former
owner had "personality problems" and had not disclosed the true
financial condition of his HHA.
A former ABC manager told us of hearing Mr. Mills state on several
occasions that the high price of salaries paid to former owners under
the employment agreements was, in part, the purchase price of the
HHAs. Referring to the former owners, the former ABC manager quoted
Mr. Mills as making such statements as the following: "I don't care
if they don't do a thing." "I would really rather they not work." "I
don't care if they come into the office or not." "I don't care what
they do." The former manager added that after he and another
management official became concerned about the impropriety of
charging Medicare for such salaries, Mr. Mills replied, "Medicare
won't pay to buy agencies but will reimburse for salaries."
Mr. Mills told us that some owners did not abide by the terms of
their agreements; thus, he subsequently released them for due cause.
In response, some of the former owners pursued legal action against
ABC. Some of these cases are still being litigated.
ABC REPORTEDLY CHARGED
NONALLOWABLE MARKETING
EXPENSES TO MEDICARE
---------------------------------------------------------- Letter :5.2
According to former employees, ABC directed them to market its
services to physicians and the community with the intent of charging
Medicare for these nonallowable expenditures. Although Medicare
reimbursement is available for the expenses of educating health
professionals and the community at large, HCFA regulations on cost
reimbursement do not provide for payment for marketing home health
care services.
The primary responsibility of certain ABC employees was to solicit
patient referrals from physicians. In return for referrals, the
employees gave physicians gifts and other items of value. Former
employees stated to us that ABC managers told them not to use the
term "marketing" when identifying the nature of such expenses but
rather to disguise it as a "health education" expense. According to
the former employees, they purchased meals or gifts for physicians on
a regular basis and gave gifts to physicians and their spouses in
recognition of special events, e.g., birthdays and new births. On at
least one occasion, a physician received golf tickets to a
Professional Golf Association tournament.
ABC also instructed employees to promise extra services for those
physicians making numerous referrals. For example, according to
individuals who attended one national ABC employee conference, a
corporate official suggested that employees tell physicians, "Give us
your next two patients, and here is what we can do for you." The
official then told the employees to elaborate on the different
services the corporation could provide at no cost in exchange for
referrals, such as the services of nurses for blood pressure
screening and lab work. According to a former employee who attended
another conference, Mr. Mills remarked that it was ". . . great
to see all my salespeople, I mean educators." Mr. Mills also said,
"We don't market here. Whatever we do is education or in-service."
Employees who attended the conference stated that attendees laughed
at Mr. Mills' comment, because they knew that their jobs were to
market ABC.
ABC used the title "Coordinator of Field Management Development"
(CFMD) for marketing employees. ABC believed that HCFA would not
reimburse the expenses for marketing but would be more likely to
reimburse the costs of a CFMD, because the latter implied community
education. When local administrators declined to submit expenses of
CFMDs for Medicare reimbursement, citing that they were not patient
care-related, Mr. Mills directed that CFMDs report their expenses to
corporation managers other than the local administrators. However,
according to HCFA and the Medicare fiscal intermediary, these
expenses are not allowable because they are not patient-related.
According to former employees, ABC managers told employees to conceal
the cost of items given to physicians in their expense reports so
that HCFA would reimburse the cost without question. Managers wanted
these costs to be labeled as "educational," "training," "luncheon,"
or "mileage" costs. Further, they told employees that to be
reimbursed, they should charge certain expenditures, such as liquor
for physicians, on their personal credit cards. This would make
tracing the true expenditures more difficult. One former employee
disclosed that his supervisor recommended purchasing a restaurant
receipt book from a stationery store for use when submitting these
types of expenses for reimbursement.
METHODOLOGY
------------------------------------------------------------ Letter :6
We conducted our investigation from January 1994 through May 1995.
It addressed issues involving ABC's participation in the Medicare
home health care program. The issues we examined included ABC's
policies and practices regarding patient eligibility and visits and
the appropriateness of certain expenses to the Medicare program. To
examine these issues, we reviewed applicable laws and regulations,
HCFA directives, correspondence between HCFA and ABC, documents
presented by ABC and its employees, and ABC and HCFA patient file
information for select locations. Finally, we reviewed court
documents and evidence presented by ABC, HCFA, a Medicare fiscal
intermediary, and individuals associated with civil litigation issues
involving ABC.
We interviewed current and former ABC employees and patients and
their families in selected locations, state regulatory officials in
several of the states in which ABC does business, federal
investigators and regulatory officials at HCFA, representatives from
two fiscal intermediaries that process Medicare claims, various home
health practitioners, and representatives of home health care trade
associations. We conducted our work in Colorado, Florida, Georgia,
Illinois, Maryland, Michigan, Pennsylvania, Tennessee, Texas,
Virginia, and Washington, D.C.
---------------------------------------------------------- Letter :6.1
If you have questions concerning this report, please contact me or
Assistant Director Barney Gomez of my staff at (202) 512-6722.
Sincerely,
Richard C. Stiener
Director
(See figure in printed edition.)Appendix I
EXCLUSION LETTER
============================================================== Letter
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
(See figure in printed edition.)
MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix II
OFFICE OF SPECIAL
INVESTIGATIONS, WASHINGTON,
D.C.
-------------------------------------------------------- Appendix II:1
Barney L. Gomez, Assistant Director for General Crimes and Health
Care
Robert J. Gettings, Special Agent
Barbara W. Alsip, Communications Analyst
RESOURCES, COMMUNITY, AND
ECONOMIC DEVELOPMENT DIVISION
-------------------------------------------------------- Appendix II:2
Richard E. Chervenak, Assistant Director
HEALTH, EDUCATION, AND HUMAN
SERVICES DIVISION
-------------------------------------------------------- Appendix II:3
Paul C. Wright, Evaluator
OFFICE OF THE GENERAL COUNSEL,
WASHINGTON, D.C.
-------------------------------------------------------- Appendix II:4
Barry L. Shillito, Senior Attorney
*** End of document. ***