Geisinger Community Health Services: Home Health Encounters, Hospice Claims, One Settlement

In the Geisinger Community Health Services home health settlement, the provider agreed to pay $18,513,621 to resolve allegations involving Medicare home health face-to-face encounters, hospice certifications and hospice elections. The government said Geisinger voluntarily disclosed the problems. For a nurse or compliance employee, the home health issue reaches a familiar handoff: the clinical encounter, the certification and the agency’s bill. We look at what each person recorded and how those records supported the request for payment.

The U.S. Attorney’s Office for the Middle District of Pennsylvania announced the civil settlement on November 1, 2021. The amount covered hospice and home health together.

What Geisinger Disclosed

According to the government’s account of Geisinger’s voluntary disclosures, the Medicare claims at issue ran from January 2012 through December 2017. The disclosures described claims submitted through several entities within the health system. The hospice allegations concerned physician certifications of terminal illness and patients’ elections of hospice care. The home health allegations concerned required physician face-to-face encounters with patients.

The hospice certification concerns terminal illness. The home health encounter belongs to the certification chain supporting home health eligibility. A review of one benefit’s files answers a different question from a review of the other’s. Combining them under a general billing label hides the decisions that made each claim payable.

The U.S. Attorney’s Office said Geisinger took corrective action after discovering the problems and disclosed them to the office. It commended the provider for that response. We see an odd pairing: a Medicare settlement and a government commendation in the same announcement.

For an insider, the useful question is what management does after a billing problem reaches its desk. If your employer identifies similar defects but keeps sending the claims, that response belongs in our assessment of the case.

What a Home Health Face-to-Face Encounter Does

A home health face-to-face encounter connects an examination of the patient to the primary reason the patient needs home health services. Medicare requires that encounter within 90 days before or 30 days after the start of care.

We follow the handoff from the referring office to the certifier and the agency: does the encounter record support the eligibility claimed in the certification? An agency assessment alone cannot answer that question.

The certification addresses homebound status and the need for qualifying skilled care, as well as the encounter and plan. The clinical basis for care is also central to unnecessary home health care allegations. Each issue calls for its own evidence: what the patient needed, what the practitioner saw, what was certified and what the agency billed.

A signature cannot supply clinical support that the underlying records lack. The practitioner or discharging facility’s records and the agency’s account need to support the same patient’s eligibility. Agency information used to support certification must be corroborated by those records and signed and dated by the certifier.

The Documentation Rule Changed During the Covered Years

For episodes beginning January 1, 2015, Medicare removed the separate general physician narrative requirement. The face-to-face encounter and supporting medical record remained required under the home health final rule.

Geisinger’s covered claims span that change. An older file and a later file therefore need to be read against the requirements for their own dates. Less narrative paperwork did not mean the encounter disappeared.

What Evidence Is Needed to Prove Fraud?

For an encounter-related home health case, we connect the clinical record and certification to the claim, payment and decisions inside the provider. We examine the encounter note and date alongside the certification, assessment, plan, visit documentation, submitted claim, adjustments and payment record. That is the work we do with you: finding where those records diverge and who knew about the problem.

The plan identifies the services, responsible disciplines, visit frequency and duration. The visit documentation shows the care recorded against that plan. The claim states what the agency asked Medicare to pay, while the remittance shows the payment result. These records can sit with different participants. Seeing the signed plan alone leaves much of the payment story unread.

The agency’s OASIS assessment has another job: it supplies information used in payment grouping and quality measurement. In OASIS upcoding cases, we examine changes to that account of the patient’s condition and their effect on payment. Encounter evidence, assessment data and the Medicare claim each need to be connected to the same care.

For a system-employed nurse, the useful knowledge may be what the patient actually needed and what appeared in the chart. For a healthcare compliance employee, it may be the finding that reached management and the response that followed. For a biller, it may be the claim submitted after that finding. We bring those views together to understand the provider’s decisions, including whether identified problems were corrected.

The Encounter Problem in Other Health Systems

Other health-system cases show why the handoff between hospital records and home health billing deserves attention. In its UPMC settlement announcement, the Justice Department described allegedly unsupported Medicare home health claims following referrals from UPMC hospitals. The missing support was documentation of a face-to-face encounter with a physician or authorized non-physician practitioner. UPMC disclosed the problem itself.

The New York Health Quest settlement supplies a different comparison. Health Quest admitted specified facts concerning insufficient home health records, including face-to-face documentation, for care from April 1, 2011 through August 2014. That resolution also addressed separate hospital and physician-billing issues.

For an insider, the recurring connection is the encounter record supporting an agency’s claim. The hospital’s referral and the agency’s billing each tell part of the story. The clinical documentation between them is where we look for the support Medicare required. A health system’s shared name does not make that handoff take care of itself.

How Much Does a Medicare Fraud Whistleblower Get Paid?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We work with your knowledge of the care and billing to connect the clinical records, claims and decisions inside the provider.

Your View of the Encounter and the Claim

If you saw a gap between the clinical encounter and the Medicare claim, speak with our whistleblower experts about what happened inside your health system. We work beside you to build the case from your knowledge of the care and billing, and bring in home health fraud whistleblower lawyers who understand the certification process. You bring the experience of what happened at work; we bring the judgment and partnership to pursue it with you.