Extended Nursing and Excellent Home Care: Paying for Unqualified Aides

The Extended Nursing Excellent Home Care settlement formed part of a $24 million resolution with three New York City home health care agencies over alleged false Medicaid and Medicare claims. The government alleged that a staffing supplier provided untrained aides with false certificates, and the agencies using those aides knowingly billed for their services. If you handled training, assignments or billing, the connection between the worker’s qualifications and the claim is the part of this case you may recognize.

The Justice Department announced the settlements on December 17, 2009. Extended Nursing Personnel CHHA and Excellent Home Care Services were the receiving agencies. Nursing Personnel Home Care supplied the aides. The alleged false training credentials crossed from one business into another’s government claims.

What Did Extended and Excellent Allegedly Bill?

Extended and Excellent allegedly billed New York Medicaid for untrained aides with false training certificates. The government also alleged that the agencies billed Medicare for aide services that were never provided.

The Medicaid allegation turned on what the program paid for. As the Justice Department explained, New York Medicaid covered home health aides only when they had valid certificates showing proper training. The United States contended that Nursing Personnel knowingly supplied aides with phony certificates and that Extended and Excellent knowingly billed for those untrained workers.

The government alleged that the receiving agencies knew the aides were untrained. We see a certificate meant to protect patients reduced, in the government’s account, to a ticket for billing. Paper qualifications. Real patients.

The Medicare allegation concerned whether the work happened. The government contended that Extended and Excellent submitted claims for home health aide services purportedly performed by Nursing Personnel’s aides but never actually provided.

How the Aide Record Crossed Three Agencies

The alleged arrangement separated the company supplying the aide from the companies billing for the aide’s work. Nursing Personnel supplied workers to Extended and Excellent, and those agencies sought government payment for their services.

A training coordinator may know what instruction an aide completed. A staffing employee may know which credential accompanied the assignment. A supervisor or biller at the receiving agency may know which worker’s services reached the claim. We connect those accounts so that the case follows the same aide through the different organizations.

The New York certificate requirement described in this settlement belongs to its Medicaid allegation. We examine the qualification required for the particular service and payer, alongside the credential the agency relied on.

The patient-care concern is concrete. The Justice Department described cutting corners on training standards as undermining the care agencies provide. Training was the assurance behind the certificate, and the government alleged that agencies billed taxpayers knowing that assurance was false. The person receiving care had a stake in whether the worker was qualified long before a claim reached Medicaid.

What the Settlement Covered

The announced recovery combined the settlements with Nursing Personnel, Extended and Excellent. The Justice Department reported approximately $9.7 million in federal recoveries and approximately $14.3 million for New York. The combined amount covered the three agencies and two whistleblower lawsuits.

Those qui tam lawsuits brought the healthcare fraud allegations under the False Claims Act. One concerned Nursing Personnel. The other concerned Extended and Excellent. The staffing supplier and the receiving agencies appeared in the same public announcement because the settlements addressed connected allegations about the aides and their billed services. The Justice Department credited a joint federal and state effort, including New York’s Medicaid Fraud Control Unit.

What Evidence Is Needed to Prove Fraud?

In an aide-qualification case, we connect the worker’s actual training, the qualification represented to the receiving agency, the services billed and what the people responsible knew. For the separate missing-service allegation, the question is what care occurred on the dates the agency charged for it.

We begin with the worker behind the credential. The training record and certificate describe the qualification claimed. The roster and assignment identify where that worker was sent. The service record and claim connect the aide to the care charged to Medicaid. A person familiar with the training may explain a discrepancy that a biller sees only as a completed personnel file. We examine the plan of care alongside what was billed, whether the concern is a missing visit or medically unnecessary home health care.

The knowledge allegation also needs its own account. We look at who supplied the credential, who received it, who authorized the worker’s assignment and what information reached the people responsible for billing. If you know why a certificate misrepresented the training, or why a service record described work that never happened, that knowledge gives the paperwork meaning.

The HHS Office of Inspector General’s 2016 personal-care advisory described pre-signed timesheets, overseas travel and simultaneous service locations in its discussion of unperformed care. It reported that most cases then came from people who knew the participants. That is the value of an insider who can explain what a completed service record conceals.

The Same Pattern in Other Home-Care Cases

Aide qualifications and service records have appeared together in other home-care settlements. The allegations connect what the agency represented about its workers to what it charged for their services.

In Hope In-Home Care’s Virginia Medicaid settlement, the government alleged untrained aides, false eligibility documentation and claims for unrendered respite care or family-provided care that failed Medicaid requirements. The personnel record, patient eligibility and service record each mattered to a different allegation.

In M&Y Care’s aide-qualification settlement, the government alleged that insufficiently trained staff’s services were billed under code G0156 instead of the non-skilled-care rate. The Justice Department described that lower rate as about 74% less at the time. The allegation connected the worker’s training directly to the price charged for the work.

In the Blessings 4 Ever Home Care Agency settlement, the government alleged fabricated or backdated training and personnel documents. A separate allegation concerned in-home claims for beneficiaries hospitalized all day. One issue called for the history of a personnel document; the other called for the patient’s location. That is why we follow both the qualifications and the claimed care.

How Much Does a Medicare Fraud Whistleblower Case Pay?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In the Extended and Excellent resolution, the Justice Department announced that the whistleblower would receive approximately $1.66 million from the government’s recovery from those agencies.

You Know How the Aide Reached the Claim

If the training file, staffing assignment or billed visit tells a story you know is false, speak to one of our Whistleblower Experts about how the agency billed for those aides. We build your strongest home health whistleblower case around your knowledge of the operation and bring in home health fraud whistleblower lawyers who understand aide qualifications and government billing. From the first conversation through the pursuit of a recovery, we stay on your side of the table.