Health Agency With Wilmington Ties Agrees To $14 Million Settlement Over Improper Medicaid Billing

BOSTON, MA — As part of an effort in Massachusetts to address fraud, waste and abuse in the home health industry, Attorney General Maura Healey announced Tuesday that a national home health agency, which a location in Wilmington, has agreed to pay more than $14 million to settle allegations that it improperly submitted and received overpayments for services from the state’s Medicaid program, known as MassHealth.

Centrus Premier Home Care Inc. d/b/a/ Maxim Healthcare Services, Inc. (Maxim), is a nationwide provider of home health and other healthcare services with six locations in Massachusetts—Needham, Plymouth, Springfield, Taunton, Wilmington and Worcester.

MassHealth referred this matter to the AG’s Medicaid Fraud Division in January 2017 after a voluntary provider overpayment disclosure by Maxim to MassHealth in October 2016. The disclosure indicated that claims were improperly submitted to and paid by MassHealth for home health aide services provided through Maxim when nursing or skilled therapy services were not necessary.

“This company billed MassHealth for services that were not eligible for reimbursement under state regulations and with the voluntary disclosure of these overpayments, will pay more than $14 million in this settlement,” AG Healey said. “Home health agencies must be diligent in their billing practices to preserve the integrity of this program, which provides critical health care services to low-income individuals across our state.”

“Under the Baker-Polito Administration, MassHealth has strengthened its program integrity efforts, including restructuring of the home health program, to reduce fraud, waste and abuse,” Health and Human Services Secretary Sudders said. “As a result of this work, a moratorium on new home health agencies was implemented in 2016 and spending in the home health program has decreased 21 percent from fiscal year 2016 to 2017.”

Eighty percent of home health spending growth had been driven by providers new to the Commonwealth since 2013.

During the relevant time period, MassHealth regulations allowed payment for home health aide services only if a patient had “a medically predictable recurring need for nursing services or therapy services” and provided that in order to “receive intermittent or part-time nursing care, the member must have a medically predictable recurring need for skilled nursing services at least once every 60 days.”

The AG’s investigation found that between March 2010 and October 2016, Maxim submitted and received payment for nearly 95,000 claims for services that were not covered per MassHealth regulations.

The settlement requires Maxim to pay $14,264,803 to MassHealth and includes compliance conditions going forward for three years. Maxim is also required to provide annual written certification to the AG’s Office of compliance with these conditions and provide training to all employees involved in the MassHealth billing process regarding applicable statutes.

This civil settlement is part of a larger effort by AG Healey and MassHealth to combat fraud, waste and abuse in the home health program.

The AG’s Office has recently taken criminal action against three home health agencies and their owners—Compassionate Homecare, Harmony Home Health Care, and Lifestream Healthcare Alliance—for allegedly overbilling and falsely billing MassHealth for home health services that were not authorized and/or provided.

In 2016, MassHealth completed a series of home health provider audits and as a result has strengthened program integrity within the home health program through a number of controls. MassHealth and the AG’s Office worked to implement new regulations, effective March 1, 2016, that add prior authorization for home health services, require documented face-to-face physician visits to authorize home health services, and prohibit certifying physicians from being on staff or under contract with the home health agency.

In fiscal year 2016, MassHealth spent approximately $750 million on home health services, a 35 percent increase compared with fiscal year 2015. Since the restructuring of the home health program, spending on home health services has decreased significantly to $617 million in fiscal year 2017.

The Maxim matter was handled by Assistant Attorney General Steven Hoffman, Deputy Chief of the AG’s Medicaid Fraud Division, and Investigators Scott Grannemann, Christopher Cecchini and Shelby Stephens, also of the AG’s Medicaid Fraud Division. Maxim fully cooperated with the Attorney General’s investigation.

(NOTE: The above press release is from the Massachusetts Attorney General’s Office.)

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