Fraudulent Nursing Diploma Scheme: 2023 Operation Nightingale Enforcement Action

CHAP

On January 25, 2023, the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) and our law enforcement partners launched a multi-state coordinated law enforcement action to capture individuals engaged in a scheme to sell false and fraudulent nursing degree diplomas and transcripts. The enforcement action resulted in the execution of search warrants in Delaware, New York, New Jersey, Texas, and Florida, and 25 individuals being charged for their involvement in the fraud scheme. More than two dozen individuals have been charged in the Southern District of Florida for their alleged participation in a wire fraud scheme that created an illegal licensing and employment shortcut for aspiring nurses.

The alleged scheme involved the selling of fake and fraudulent nursing degree diplomas and transcripts obtained from accredited Florida-based nursing schools to aspiring Registered Nurse (RN) and Licensed Practical/Vocational Nurse (LPN/VN) candidates. The individuals who acquired the bogus nursing credentials used them to qualify to sit for the national nursing board exam. Upon successful completion of the board exam, the nursing applicants became eligible to obtain licensure in various states to work as an RN or a LPN/VN. Once licensed, the individuals were then able to obtain employment in the health care field. The overall scheme involved the distribution of more than 7,600 fake nursing diplomas and transcripts. The following schools that issued the fake diplomas and transcripts schools are now closed.

• Siena College – Broward County, FL
• Palm Beach School of Nursing – Palm Beach County, FL
• Sacred Heart International Institute – Broward County, FL

CHAP suggests that organizations proactively review the education for all nurses on staff to ensure they do not have practicing nurses with diplomas/transcripts from any of these schools. Organizations should only employ professionals who furnish services directly, under an individual contract, or under arrangements who are legally authorized/licensed in accordance with applicable Federal, State and local laws. Nurses who have not been educated by legitimate accredited nursing schools do not have the proper training and skills to care for patients in any healthcare setting. This is not only a compliance issue, but a patient safety and quality of patient and family care issue.

View the OIG’s 2023 Operation Nightingale Enforcement Action.

Impending Onset of Medicare Home Health Clawback Payments Gnaws at Providers

McKnight’s Home Care | By Liza Berger
 
Home health providers have been laser-focused in recent months on the permanent Patient-Driven Groupings Model payment cut — 3.925% — which went into effect on Jan. 1. But there is a looming cut that threatens even more instability for providers: the temporary clawback payments related to PDGM. These reductions, which are expected to total at least $3 billion, may take effect as soon as next year.  
 
“I can’t say you can rate one as scarier than another,” Bill Dombi, president of the National Association for Home Care & Hospice, said of the permanent and temporary cuts to McKnight’s Home Care Daily Pulse. “In combination, they are a disaster.”
 
Capstone, a global policy analysis and regulatory due diligence firm, might agree. In a recent policy analysis of “underappreciated developments in healthcare in 2023,” it found that temporary clawbacks in 2024 “represent a potentially larger threat to home health,” than a cut to the market basket.
Other home health leaders have voiced serious concerns about the clawback payments.
 
“We are very, very concerned about what happens in ’24,”  Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare, told McKnight’s Home Care Daily Pulse. “It’s not a positive picture at all for home health. It’s pretty dire. They are significant reductions to the Medicare home health program. They won’t be implemented without significant harm to patient access.”
 
It’s not clear yet exactly how much money home health will owe from the temporary cuts related to PDGM overpayments and when. The proposed home health rule, which is due out this summer, will give providers a glimpse of what CMS is planning and how it intends to levy the adjustment, Cunningham said.
 
“The heat is dialed up now that we are looking at 2024,” she said. “We should see in rulemaking exactly how they are going to extract those [payments], which they didn’t do in 2023.”
 
The temporary PDGM cuts, like the permanent reductions, are a result of CMS’ overpayments to home health as a result of the transition from the old payment to PDGM in 2020. Home health providers likely owe at least $1 billion each year between 2020 and 2022. Both NAHC and the Partnership disagree with the methodology that CMS used to arrive at the overpayment figures.
 
This year, both organizations are going to continue to argue this point to members of Congress. They believe they have convinced Congress of their position somewhat, as the recent omnibus bill, which passed into law, required CMS to provide transparency around how it arrives at rate cuts.
 
Dombi thinks it is unfair to target traditional Medicare home health for cuts as the program helps to subsidize the underpayment from Medicaid and Medicare Advantage. His organization is pushing CMS to suspend all cuts in 2024 until there is a recognition of a need to fundamentally overhaul the payment system.
 
“We need to create a bridge between today and tomorrow without disruption,” he said.

CMS Resources on Strengthening the Direct Service Workforce

NAHC Report

Direct service workers provide essential supports to older adults and people with intellectual and developmental disabilities, physical disabilities, and behavioral health needs.  The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the release of an online training course and a series of resources that offer strategies and information on self-direction, strengthening the direct service workforce (DSW) in rural areas, and strategies emerging from CMS’ 2021 DSW State Medicaid Learning Collaborative.

Although the resources are from CMS, private duty operators should be aware that they are useful for private duty, as well.

Each resource is described below.

• The online training, Recruiting, Selecting, and Retaining Direct Service Workers to Provide Self-directed Home and Community-Based Services (HCBS), provides guidance and information for people who self-direct, or wish to self-direct, their HCBS, as well as others interested in information on finding, hiring, and retaining direct service workers. The interactive training is free to access.
• Strengthening the Direct Service Workforce in Rural Areas summarizes the challenges of ensuring an adequate DSW in rural areas and strategies that state Medicaid and partner agencies and rural stakeholders can use to deliver high-quality HCBS.
• The Self-direction Briefing Paper Series is designed for policymakers and stakeholders to inform conversation and policy regarding HCBS self-direction and the DSW.
• Emerging Strategies for States: DSW Learning Collaborative Summary summarizes themes, challenges, and strategies from state Medicaid and partner agencies participating in CMS’ 2021 DSW State Medicaid Learning Collaborative.

Medicare Hospice Claims Denials – Campaign to Reduce Denials

CGS, a Medicare Administrative Contractor, is leading a campaign to reduce Medicare hospice claims denials. The top reason Medicare denies hospice claims centers on insufficient documentation, which is projected to result in $2.9 billion in improper payments.

Given that, they are sharing free information and tips for providers to help reduce denials. They will be sharing an e-mail series, short videos, a webinar, and a CME/CE e-learning module training. Topics include:

• How to properly document Certification of Terminal Illness
• How to submit documentation in response to Additional Documentation Requests (ADRs).