Deaconess Home Health: Inflated Assessments and Missing Supervisory Visits

In the Deaconess Home Health fraud settlement, the company and its owner agreed to pay $3,724,000 over alleged false Wisconsin Medicaid personal-care claims. The Justice Department’s account of the criminal charging document described inflated assessments, missing supervisory visits and physicians signing plans without examining patients. For a nurse who knew the patient’s actual needs, or a biller who saw claims the care records could not support, those are different views of the same problem: the agency’s account of the care had allegedly become detached from the patient.

The Justice Department announced the civil settlement on November 18, 2015. Deaconess, a Wisconsin healthcare agency formerly known as Outreach Home Health, provided personal-care worker services billed to Wisconsin Medicaid. The settlement resolved three whistleblower lawsuits, and two of the whistleblowers were former Deaconess employees.

The Personal Care Wisconsin Medicaid Was Paying For

Wisconsin Medicaid paid for medically oriented personal-care services that helped recipients with daily activities so they could remain in their homes in the community. Deaconess allegedly billed for care that was medically unnecessary or that it could not verify had been provided.

Medicaid has separate home-health and personal-care benefits, with different authorization arrangements. Federal personal-care rules recognize physician authorization through a treatment plan or state-approved authorization through a service plan.

Here, the government’s allegations follow the work from recruiting a patient to assessing need, signing a plan, supervising services and submitting a claim. Each stage had a person responsible for what the agency said about the care.

Inflated Assessments and Missing Supervisory Visits

The Justice Department’s account of the criminal charging document and agreed statement of facts described four alleged practices inside Deaconess. They reached both the decision to provide personal care and the records used to support Medicaid billing.

Recruiting Without Regard to Need

The criminal charges alleged that Deaconess and its owner intentionally recruited patients and personal-care workers without regard to whether the patients medically needed the services. Recruitment came before the assessment and plan that would support the claim.

That places the intake decision inside the alleged scheme. An agency looking for people to bill for can put pressure on the next person in the process: the nurse expected to describe why those people need care.

Telling Nurses to Inflate Assessments

The criminal charges alleged that Deaconess instructed its nurses to routinely inflate patient assessments sent to Medicaid, without regard to medical necessity. For the nurse, the comparison is concrete: what the patient needed, what the assessment reported, and what someone inside the agency told the nurse to write. We see the absurdity in recruiting without regard to need and then asking the clinical staff to manufacture the need on paper. The assessment was supposed to describe the patient.

Leaving Out the Supervisory Visit

The criminal charges also alleged that Deaconess failed to conduct required supervisory visits. Those visits were supposed to establish that services were being provided, remained medically necessary and were appropriate for the patient’s needs.

Missing that visit left more than an empty space in a file. It removed a check on whether the care behind the claim was happening and whether the patient still needed it.

Signing Plans Without Examining Patients

The criminal charges further alleged that Deaconess hired physicians as medical directors to sign plans of care for patients they had not physically examined. The signature, assessment and supervisory visit served different purposes. Taken together, the allegations describe an agency claiming support for personal care while bypassing the work that was meant to establish the patient’s need and check the care delivered.

Unnecessary Care and Unverified Care

The government’s account of the criminal charges identified two problems with the resulting claims: services that were not medically necessary and services Deaconess could not verify had ever been provided. A nurse’s account of the patient’s condition speaks to the first problem. Records of who attended, what they did and when they did it speak to the second. An assessment describing greater need cannot answer whether a worker actually delivered the billed care. A visit record cannot answer whether the assessment was inflated.

The Justice Department reported that Deaconess’s Medicaid personal-care billing increased by over 100% between 2011 and 2012. The government’s account puts that growth beside routine inflation of assessments and missing supervisory visits. More billing, without the checks behind it. Deaconess ceased operating after Medicaid stopped paying its claims in April 2013.

Three Whistleblower Cases, One Civil Settlement

The Deaconess civil settlement resolved three qui tam cases under the False Claims Act. The Justice Department identified two whistleblowers as former employees and announced a collective payment to the whistleblowers. Their place inside the agency matters: the alleged instructions to nurses and the missing supervisory work concern decisions that a claim form alone would not explain. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

The same announcement described a separate criminal case against the company and its owner. It said Deaconess had agreed to plead guilty and described a proposed agreement to defer prosecution of the owner.

Atlas Had a Separate Settlement

Atlas Healthcare and its owners agreed to pay $435,000 in a separate civil settlement, announced the same day. The government alleged that the Hales Corners, Wisconsin agency billed Medicaid for personal-care services patients did not need, or for more care than they needed. One of the whistleblower cases resolved by Deaconess was also the case resolved by Atlas. The Atlas allegations sharpen the assessment issue: a claim can overstate a patient’s needs by billing an excessive level of personal care.

What Evidence Is Needed to Prove Fraud?

Proving allegations like these means tying the patient’s actual needs, the agency’s instructions and the care records to the claims. We work with insiders to understand where those accounts diverge and who made the decisions behind them.

A separate whistleblower complaint against Family First Home Health Care in North Carolina makes the supervision issue tangible. The complaint alleged that the agency billed a supervisory visit under an employee who no longer worked there:

That complaint also alleged fabricated service dates and times, care recorded at addresses where patients no longer lived, and forged caregiver and patient signatures. These are allegations about Family First. They show why the worker’s employment record and the patient’s circumstances can matter as much as the completed form.

For today’s personal-care agencies, electronic visit verification adds service dates, locations, worker identities and start and end times to that comparison. The HHS Office of Inspector General’s personal-care oversight work identified gaps in attendant identity, qualifications, task authorization and delivery documentation. Those gaps matter to the same question raised by the alleged missing supervisory visits: who checked that the patient received the care Medicaid paid for?

A nurse may know the assessment was changed. A supervisor may know the listed visit did not take place. A billing employee may know which claim used those records.

You Know What the Patient Needed

If you saw assessments inflated or supervisory visits recorded without the work behind them, speak to one of our Whistleblower Experts about how the care was billed. We build your strongest Medicaid whistleblower case around what you know about the health care, bring in Medicaid fraud whistleblower lawyers who understand personal-care billing, and stay beside you throughout the case.