Health Quest New York: Admitted Face-to-Face Documentation Failures

The Health Quest New York home health settlement required more than $14.7 million to resolve False Claims Act allegations involving unsupported home health claims, inflated medical billing and alleged hospital referral payments. Health Quest admitted submitting home health claims without sufficient medical records, including documentation of a face-to-face physician encounter. For someone in intake, clinical documentation or billing, that is the part worth examining: the business asked the government to pay when its records did not support the claim.

The Justice Department announced the resolution on July 9, 2018. The federal payment covered hospital and home-health claims together. Health Quest also agreed to pay an additional $895,427 to New York, which jointly funds its Medicaid program with the federal government.

The New York Health System Behind the Claims

Health Quest Systems was a New York family of integrated hospitals and healthcare providers delivering surgical, medical and home health care. Putnam Hospital Center, its subsidiary hospital in Carmel Hamlet, was part of the resolution. The case reached different parts of that business: home-care records, evaluation-and-management billing, and the hospital’s compensation arrangements with referring physicians.

Healthquest in Palm Beach, Florida faced allegations that payments to marketers induced Medicare home health referrals. That is a separate company and a separate case about payments for patient recruitment. In the New York home-health component, the central admission concerned claims whose medical records fell short.

What Health Quest’s Home Health Claims Lacked

Health Quest admitted that, from April 1, 2011 through August 2014, it submitted home health claims lacking sufficient medical records, including documentation of a face-to-face encounter with a physician. The government’s account of the admissions puts the failure where it belongs: between the clinical record and the request for payment.

The encounter has a specific job in home health certification. It connects a patient’s clinical condition to the reason for home health care. Certification brings together the findings that support eligibility, including homebound status, skilled need and a plan of care.

The physician or discharging facility may hold the clinical support for the referral, while the agency holds its assessment, plan and visit records. Billing holds the claim and payment information. We examine how those accounts fit together, because a signature cannot supply clinical facts that the records lack.

The distinction also matters for staff who work with OASIS assessment data and payment. OASIS supplies information used in payment grouping and quality measurement. Certification addresses eligibility, while the claim requests payment. Treating the agency’s assessment as the whole clinical foundation leaves the encounter and certifier’s supporting records out of view.

We expect the provider asking taxpayers to pay for home care to have the medical records to support its bill. The claim went forward. The clinical support fell behind.

Why the Encounter Dates Matter

Health Quest’s admitted home-health period fell under the older face-to-face documentation framework. The Medicare home health rule for 2015 removed the general requirement for a separate face-to-face narrative for episodes beginning January 1, 2015. The encounter requirement and the need for supporting medical records remained.

Health Quest’s admitted claims came before that change. We examine the records used to support the bill under the requirements for that care period.

Different Billing Decisions Inside One Settlement

The resolution also addressed Health Quest’s evaluation-and-management billing and Putnam’s hospital referrals. The issues involved services billed above the level supported by the medical record and physician compensation allegedly intended to induce hospital referrals.

Medical Services Billed Two Levels Too High

Health Quest admitted billing evaluation-and-management services two levels higher than the medical record supported. That conduct ran from April 1, 2009 through June 23, 2015.

For a coder or billing employee, the comparison is concrete: the level submitted on the claim against the services documented in the chart. The home-health admission concerned insufficient records supporting the claim. Here, the admitted mismatch reached the billed level itself. Different billing decisions, the same demand on the clinical record to justify the money requested.

Putnam’s Payments to Referring Physicians

The United States alleged that Putnam submitted false claims for inpatient and outpatient services referred by two orthopedic physicians from March 1 through December 31, 2014. The physicians received compensation for administrative services. The government alleged that the compensation exceeded fair market value and that one purpose of the excess was to induce referrals to Putnam.

The Justice Department described those hospital claims as alleged violations of the Physician Self-Referral Law and the Anti-Kickback Statute. The referral destination was the hospital. The home-health claims involved the separate documentation failure Health Quest admitted.

For an insider, these lead to different records. Compensation agreements and payments explain the financial relationship alleged in the hospital claims. Clinical records and claim submissions explain the admitted home-care documentation problem. We follow the decision made in each part of the business and the claims that followed it.

Former Employees Brought the Whistleblower Cases

Former Health Quest employees brought three qui tam lawsuits under the False Claims Act, and the settlement resolved them together. The Justice Department announced separate awards for a whistleblower in each of two actions and a pair of whistleblowers in the third. One former employee was to receive approximately $1.9 million. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

The Agreement on Future Compliance

Health Quest agreed to enter into a Corporate Integrity Agreement with the Department of Health and Human Services’ Office of Inspector General to address future compliance. The resolution included specific factual admissions from Health Quest and Putnam. For the home-health reader, the useful result is the company’s acceptance of responsibility for submitting claims without sufficient supporting medical records.

What Evidence Is Needed to Prove Fraud?

In a home-health documentation case, the evidence connects the clinical record to the claim and shows who made the decisions behind it. We examine who created or changed the records and what instructions accompanied those decisions.

A related case shows why the appearance of a completed file deserves close attention. In its May 26, 2017 Abington Memorial Hospital settlement announcement, the Justice Department described allegations involving copied physician signatures on home-care Medicare claims. The hospital agreed to a $491,672 settlement. An employee allegedly cut and pasted signatures, giving records the appearance of authorization.

Health Quest admitted insufficient support. Abington resolved allegations that copied signatures stood in for physician authorization. Together, the cases show why we look beyond whether a file appears complete to how its contents were produced and whether they support the claim.

The person who knows that history may work in nursing, intake, coding or billing. A nurse may understand what the patient actually needed. An intake worker may know which records arrived with the referral. A biller may know what was submitted despite the gap. We bring those views together with the supporting records so that the case follows the work inside the business.

When You Know Why the File Fell Short

If you saw home health claims go out while encounter records or clinical support were missing, talk with our whistleblower experts about the decisions behind those bills. We build the case with you, bring in home health fraud whistleblower lawyers who understand certification and health-system billing, and stay beside you through the case.