On November 22, 2021, PruittHealth, Inc. (“Pruitt Health”), a Georgia-based health-care provider, agreed to pay $4.2 million to resolve allegations that it submitted claims for home health services that were not covered by the Medicare and Medicaid programs.  Specifically, the Government alleged that Pruitt Health knowingly submitted claims for home health services that were not eligible for reimbursement because they did not have the required face-to-face certifications or plans of care and did not document the beneficiary’s homebound status and needed skilled care.

In order for a Medicare or Medicaid beneficiary to eligible for the Medicare Home Health Benefit, the beneficiary must be “homebound” (as defined by Medicare guidelines) and need skilled care–such as skilled nursing services or skilled therapy.  However, there is a long history of home health companies billing Medicare for services for beneficiaries that do not meet these requirements.  For instance,  beneficiaries who are able to regularly leave home are not “homebound” and do not need taxpayer-funded nurses and therapists to provide care in the home, but the beneficiary can travel to a clinician to receive care.  Therefore, when a Medicare beneficiary, on home health care, is able to regularly leave home or able to travel, it strongly indicates that the beneficiary is ineligible for home health care.

As a result of widespread fraud in the submission of home health claims, Medicare and Medicaid began requiring referring physicians to certify in writing that the physician met with the beneficiary “face-to-face” and the beneficiary was homebound and needed skilled care.  Therefore, as the Pruitt Health settlement demonstrates, when required face-to-face visits and plans of care are not documented appropriately, the False Claims Act is violated.

These allegations were originally brought by a former employee of Pruitt Health under the qui tam provisions of the False Claims Act.  Under the False Claims Act,  private citizens (known as “Relators”) may bring a lawsuit on behalf of the United States and share in any recovery obtained by the government.  The Relator will receive over $700,000.00 from the Pruitt Health settlement.

Frohsin Barger & Walthall would like to thank and congratulate the brave whistleblower that came forward in this case, as well as her attorney Mr. Jack Rosenberg in Atlanta, Georgia.

Read the full Department of Justice press release here.

If you have questions about the False Claims Act or home health care fraud, please contact Frohsin Barger & Walthall.