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Know what we’re lobbying for!

Posted on: March 24th, 2012 by accreditednursing

As the  Accredited team prepares for their march to Washington D.C., take the time to find out what we’re lobbying for.  Know the issues and our stance on it.

California Association for Health Services at Home

  • Protect companionship services exemption under wage and hour laws: Congress should  maintain the companionship services exemption at the state and federal level until a comprehensive plan can be implemented that addresses service funding, worker health insurance, and career development. Congress should block any attempt by the Department of Labor to modify the existing and longstanding definition and application of the companionship services exemption, and support legislative efforts to maintain the current companionship services exemption.




  • Oppose a “sick tax”— block efforts to impose a fee paid by patients to access Medicare home health: Congress should oppose any copay or deductible proposal for Medicare home health services and should prohibit Medicare Advantage plans from charging a home health copay or deductible. The imposition of a home health copay or deductible would be a “sick tax” on some of the oldest, poorest, sickest Medicare beneficiaries, restricting access to home health services and leading to an increase in costly hospitalizations and nursing home stays.
  • Ensure Full Market Basket Updates to Medicare Home Health.  Congress should reject any proposals to reduce the market basket inflation update or impose additional rate reductions for home health agencies. Congress should maintain its carefully crafted schedule of payment rate changes as contained in PPACA in order to secure access to continued care.



  • Ensure the Full Market Basket Update for Medicare Hospice Benefit:  Congress should restore the market basket update, rescind productivity reductions authorized under P.L. 111-148, and reject any further proposals to cut the hospice market basket update. A study of the need for refinements in the Medicare hospice benefit as recommended by the Government Accountability Office and MedPAC should be conducted before any cuts in reimbursement are undertaken. Also, Congress should oppose any reductions in the annual updates until such time as all payment reforms are instituted and then only after the issues are fully examined.




  • Establish Medicaid Home Care as a Mandatory Benefit and Support Rebalancing of Long Term Care Expenditures in State Medicaid Programs in Favor of Home Care: Congress should ensure that CMS properly implements the Medicaid home care expansion in PPACA and encourage broader coverage of home and community-based services under Medicaid. Congress should establish firm deadlines for Olmstead/ADA compliance with the penalty of lost federal financial matching payments for failure to meet the deadlines.  Further, Congress should authorize an increase in the federal matching payment for expanded Olmstead/ADA-compliant home and community-based services, and 100 percent federal reimbursement for state Medicaid compliance costs in transitioning to improve home care alternatives. Congress should monitor carefully any shift of Medicaid beneficiaries into managed care and ensure that the patients’ rights to home care under the ADA and the Olmstead decision are fully secured.



Background: In 1974, Congress established an exemption for companionship services from the Minimum Wage and Overtime Requirements of the Fair Labor Standards Act.  Congress made a societal choice in balancing the interests of the worker relative to the needs for care to the elderly and the infirm. Current law provides the Secretary of the U.S. Department of Labor (DOL) the authority to define and determine the scope of the companionship exemption.


In June 2007, the US Supreme Court ruled that the DOL companionship services exemption regulation was valid thereby reversing the Court of Appeals in a final decision.  Since the Supreme Court ruling, there has been a re-focusing of efforts by some opposed to the DOL rule. Currently, they are attempting to get Congress to change the law while also seeking legislative and/or regulatory remedies at the state level. Legislative efforts in the 110th, 111th and 112th Congresses intended to eliminate the current companionship services exemption for home care aide workers is opposed by the California Association for Health Services at Home (CAHSAH) and the National Association for Home Care & Hospice (NAHC)  because they do not go far enough to protect workers.


Some states already have passed laws that eliminated the companionship services exemption. In others, there are efforts to interpret the regulations in a manner different than the federal rules. Advocates for changing the exemption have expanded their efforts with the Obama administration to encourage DOL to change the regulation. These efforts include enlisting the aid of 15 Senators to send a letter to the Secretary of Labor requesting that the exemption be modified through regulation to exclude home care aides employed by agencies or family of the client. DOL issued a proposed rule on December 27, 2011 that would significantly restrict the exemption and make it inapplicable to workers employed by home care companies.


In the absence of a mandate that government payment programs increase payment rates to cover the added cost of wages that would result from these efforts, home care aide employers are expected to restrict working hours to avoid overtime pay. Further, these efforts do nothing to create career opportunities for home care aides or to address their need for health insurance. This isolated action related to a single element of the home care aide working conditions will have a reverse negative impact on those workers.


Legislation has been introduced in the 112th Congress that is intended to codify the current definition of companionship services. CAHSAH and NAHC are supportive of the “Companionship Exemption Protection Act” (H.R.3066) because it creates certainty for home care providers and patients rather than leaving the definition open to changes through the regulatory process.


Recommendation: A companionship services exemption under wage and hour laws should be maintained at the state and federal level until a comprehensive plan can be implemented that addresses service funding, worker health insurance, and career development. Congress should block any attempt by the Department of Labor to modify the existing and longstanding definition and application of the companionship services exemption, and support legislative efforts which maintain the current companionship services exemption.


Rationale: Most home care providers are small businesses with limited resources. The proposed regulatory changes to the companionship exemption would reduce availability of care to the elderly and the infirm and increase the costs of service delivery with no corresponding increase from third party payers, such as Medicaid.  A comprehensive rather than a piecemeal approach to worker compensation and working conditions is necessary if access to high quality of care and continuity of services is to be achieved.



Background:   The Medicare home health benefit has undergone a series of cuts since legislation was enacted to move it toward a prospective payment system (PPS).  Through a combination of legislated and regulatory cuts since 2000, payment rates are over 14 percent less than they would have been otherwise.

 Under the fiscal year (FY) 1999 omnibus appropriations legislation, the Medicare home health market basket index – used to adjust payments for inflation – was reduced 1.1 percentage points from the projected 3 percent update in each of (FY) 2000-2003.  During 2000, Congress restored the full market basket update for FY 2001. In October 2002, a major cut to home health payments of more than 7 percent that was enacted as part of the Balanced Budget Act of 1997 (BBA) was allowed to go forward.

 As part of H.R.1, The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress enacted reductions of 0.8 percent off the market basket update from April 2004 through December 31, 2006. In early 2006, Congress approved legislation (S. 1932) that eliminated a scheduled 2.8 percent market basket inflation update for 2006.

 In 2007 and 2008, the Bush Administration proposed deep cuts to the home health program as part of its budget, including recommendations that home health rates be frozen for five consecutive years. During 2007, Medicare enacted regulatory cuts of 2.75 percent in each of 2008, 2009, and 2010. In 2011 and 2012, additional regulatory cuts of 3.79% were imposed.

 Congress’ legislative action to reduce market basket inflation updates in recent years was taken, in large part, as the result of recommendations by the Medicare Payment Advisory Commission (MedPAC).  During 2003 MedPAC recommended that Congress freeze home health payment rates at the FY 2003 level for FY 2004. MedPAC renewed its market basket freeze recommendation for 2005, 2006, 2007, and 2008.

 In March 2009, MedPAC recommended elimination of the home health market basket update for 2010. MedPAC also recommended advancing a scheduled regulatory “case-mix creep” cut from 2011 to 2010. The combined impact of the MedPAC proposals, on top of an already-scheduled 2010 case mix cut, would result in payment rates during 2010 that are a full 5.5 percent below payments being made in 2009.

 In March 2010, MedPAC again recommended elimination of the home health market basket update for 2011, as well as rebasing of rates to “reflect the average cost of providing care.” Additionally, MedPAC suggested that Congress direct the Secretary of Health and Human Services (the Secretary) to modify the home health payment system (through possible use of risk corridors and blended payments) to protect beneficiaries from “stinging or lower quality of care” in response to rebasing. MedPAC also recommended that the Secretary identify categories of patients likely to receive greatest clinical benefit from home health and develop quality outcome measures for each category of patient. Finally, MedPAC recommended that Congress direct the Secretary to review agencies that exhibit unusual patterns or claims for payment and provide authority to the Secretary to implement safeguards (including a moratorium, preauthorization requirements or suspension of prompt payment requirements) to address high risk areas.

 MedPAC’s recommendations are predicated on findings of “excessive” Medicare profit margins for freestanding agencies. More comprehensive study of agency margins performed by the National Association for Home Care & Hospice has found significantly lower Medicare profit margins that virtually disappear when all payers are taken into account. Further, when agency profit margins are considered on an individual basis, they reflect dramatic ranges.

 In recent years, MedPAC has also expressed interest in imposition of a “productivity adjustment” which would reduce payments to Medicare providers to reflect gains in productivity.

To help finance a portion of health reform legislation, Congress set a reduction in the Market Basket Index of 1 point in 2011, 2012, and 2013. In addition, PPACA institutes rebasing of payment rates in 2014 with a 4-year phase-in approach and rate reductions capped annually during the phase-in at 3.5%. A productivity adjustment reduction to the Market Basket Index begins annually in 2015 at an estimated 1 point reduction per year.

 The 2011 MedPAC recommendations include a zero Market Basket Index update in 2012, accelerating the rebasing to 2012 with no more than a 2-year phase-in, and applying the productivity adjustment starting in 2012. MedPAC also recommends a new case mix adjustment model and the use of some form of limits on provider profits. Finally, MedPAC suggests imposing cost-sharing on Medicare beneficiaries use of home health services.

 Recommendation: Congress should reject any proposals to reduce the market basket inflation update or impose additional rate reductions for home health agencies. Congress should maintain its carefully crafted schedule of payment rate changes as contained in PPACA in order to secure access to continued care.

 Rationale: Since legislative changes instituted in 1997 and subsequent imposition of a PPS for home health, reimbursement levels have failed to adequately cover the rising costs of providing care, including increased labor costs for home health agencies. Thousands of home health agencies closed following implementation of the 1997 Balanced Budget Act (BBA). In calendar year 2000, one million fewer beneficiaries received home health services than in calendar year (CY) 1997 and, in the first year of PPS (CY 2001), an additional 300,000 fewer beneficiaries received home health services than in CY 2000. In CY 2001, 5.5 percent of Medicare beneficiaries received home health services, compared to 6.5 percent in 1991.  Recent study by MedPAC and CMS indicate that a major problem with the PPS is that the case mix adjustor in most cases does not accurately predict the costs of providing care.

 Under PPS refinement regulations promulgated during 2007-2010, CMS included four years of reductions to the home health base payment rate – 2.75 percent in each of 2008, 2009, and 2010, and 3.79 percent in 2011 and 2012, for a total of over $20 billion in cuts over a ten year period. These cuts could well send the home health network into severe financial difficulties similar to those experienced after passage of the BBA. This would ill serve beneficiaries, agencies, and the Medicare program.

 It is estimated that with the MedPAC proposals, well in excess of 50% of all home health agencies will be paid less than the cost of care in 2012 and there are no revenue sources to offset these losses. That means that access to care will be lost to a significant number of Medicare beneficiaries. A similar arbitrary rate-cutting effort in 1998 led to the loss of care to nearly 1.5 million home health patients, forced the closure of over 4000 home health agencies, and increased overall Medicare spending because of the expanded use of more expensive care.

 Crude measures such as across-the-board reductions or freezes will only exacerbate inequities in the system, and contribute further to access concerns. Access to care continues to be a serious problem in home health, and it is anticipated that these concerns will only increase with further cuts to home health payments. Home health care is efficient and effective in providing vital services to patients in the comfort of their homes.  Use and provision of these services should be encouraged, not discouraged.



Background: The Patient Protection and Affordable Care Act (PPACA) requires the development of Medicare hospice payment system reforms along the lines recommended by the Medicare Payment Advisory Commission (MedPAC) in 2009 and again in 2010 (Section 3132(a)). Under the new law (P.L. 111-148) the effective date for collection of data is January 1, 2011, with system reforms in operation no earlier than October 1, 2013.  P.L. 111-148 also includes interim hospice payment changes, including the institution of a productivity adjustment to the annual market basket inflation update beginning in FY2013. In addition, the final reform bill reduces the market basket index by 0.3 points for FY2013 through 2019, but conditions the 0.3 point market basket reductions in each of FY2014 – 2019 on growth in the health insurance-covered population exceeding 5 percent in the previous year. In 2011, MedPAC recommended to Congress that the hospice market basket update be limited to 1 percent for FY2012; this recommendation was not approved by Congress.  It is expected that early in 2012 MedPAC will recommend that the FY2013 market basket update for hospice be limited to 0.5 percent.

Recommendation: Congress should restore the market basket update, rescind the productivity reductions authorized under P.L. 111-148, and reject any further proposals to cut the hospice market basket update. A study of the need for refinements in the Medicare hospice benefit as recommended by the Government Accountability Office (GAO) and MedPAC should be conducted before any cuts in reimbursement are undertaken.  Also, Congress should oppose any reductions in the annual updates until all payment reforms are instituted and then only after the issues are fully examined.


•     In FY2010, the Centers for Medicare and Medicaid Services (CMS) began phasing out by regulatory issuance the Budget Neutrality Adjustment Factor (BNAF) to the hospice wage index over seven years. In each year the phase out reduces scheduled annual increases by 0.6 percent. It is estimated that the phase-out, when completed, will reduce hospice payments by 4 percent.

•     MedPAC has projected that Medicare hospice financial margins for 2012 (without consideration of costs related to volunteer and bereavement services) will average about 5 percent; however, financial margins vary widely in the hospice sector, and many hospices are operating at serious financial risk. Additionally, there is some concern that MedPAC’s estimates may not take into full account costs associated with the face-to-face encounter requirements that went into effect Jan. 1, 2011.

•     A Duke University study showed that patients who died under the care of hospice cost the Medicare program an average of about $2,300 less compared with those who did not. In its June 2004 report on the Medicare hospice benefit, the GAO determined that 34 percent of hospices in 2000 and 32 percent in 2001 had higher costs than reimbursements. A cut in the market basket update would impair the ability of hospices to maintain Medicare beneficiary access to care.

•     The GAO recommended that CMS should collect comprehensive, patient-specific data on the utilization and cost of hospice visits and services to determine whether the hospice payment categories and methodology require modification. It did not recommend an across-the-board cut in hospice payments. CMS is in the process of collecting such data for analysis.

•     At its November 2008 and subsequent meetings, MedPAC discussed potential recommended revisions to the Medicare hospice benefit reimbursement system. There is concern about the costs of short stay patients not being fully covered under the current reimbursement system. Financial margins for hospices with shorter stay patients are generally significantly lower than those of hospices serving long-stay patients. Paying accurately for all types of patients is important to ensure access to services for all Medicare beneficiaries who want to elect hospice care and to ensure that the program is paying rates that cover providers’ costs for all types of patients.




Background: Copayments for Medicare home health services have been advanced in Congress as a means of deficit reduction as well as a means of limiting the growth of Medicare home health expenditures. Some Medicare Advantage (MA) plans have imposed home health copays. Copays are regressive, inefficient and fall most heavily on the poorest and oldest Medicare beneficiaries.

The National Commission on Fiscal Responsibility and Reform (2010) recommended a uniform 20 percent copay and a uniform overall deductible of $550 for all Medicare services combined, including home health care. In January 2011 the Medicare Payment Advisory Commission (MedPAC) voted to recommend a home health copay (as much as $150 per episode) for episodes not preceded by a hospital or nursing home stay as a means to encourage beneficiaries to control utilization of care.

 Recommendation: Congress should oppose any copay or deductible proposal for Medicare home health services and should prohibit Medicare Advantage plans from charging a home health copay or deductible.

 Rationale: Home health cost sharing would create a significant barrier for those in need of home care and lead to increased use of more costly institutional care.

•     Congress modernized the home health benefit by eliminating copays in 1972 and a home health care deductible in 1980 to encourage use of less costly, non-institutional services.  The Urban Institute’s Health Policy Center concluded that copays “…would fall on the home health users with the highest Medicare expenses and the worst health status, who appear to be using home health in lieu of more expensive nursing facility stays.”  (“A Preliminary Examination of Key Differences in the Medicare Savings Bills,” 7/13/97.)

•     A study published in the New England Journal of Medicine (“Increased Ambulatory Care Copayments and Hospitalizations among the Elderly,” January 2010) found that increasing copays on ambulatory care decreased outpatient visits, leading to increased acute care and hospitalizations. It concluded that raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and increase total spending on health care. The same adverse health consequences and more costly acute care and hospitalizations would likely result from the imposition of a home health copay.

 Copayments are an inefficient and regressive “sick tax” that would fall most heavily on the oldest, sickest, and poorest Medicare beneficiaries.

•     About 86 percent of home health users are age 65 or older – 70 percent age 75 or older. More than 60 percent of all users are women. Home health users are poorer on average than the Medicare population as a whole. About 43% of home health users have limitations in one or more activities of daily living, compared with 9% of beneficiaries in general.  (AARP, “Home Health Copayment Would Have Negative Consequences for Medicare Beneficiaries,” 8/7/98.)

•     The Commonwealth Fund cautioned lawmakers that cost-sharing proposals, such as a copayment on Medicare home health services, could leave vulnerable beneficiaries at risk and place an inordinate burden on those who already face very high out-of-pocket costs. (“One-Third At Risk: The Special Circumstances of Medicare Beneficiaries with Health Problems,” 9/01).

•     Even if Medicaid recipients with low incomes were exempted from the home health copay, a large percentage of low income beneficiaries would be ineligible for protection from the home health copay because of the restrictive asset limitation, which has not been adjusted since 1989 and serves as a major barrier. (The Commonwealth Fund, “The Role of the Asset Test in Targeting Benefits for Medicare Savings Programs,” October 2002.)

Home care patients and their families already contribute to the cost of their home care.

•     According to the AARP Public Policy Institute (“Medicare Beneficiaries’ Out-of- Pocket Spending for Health Care Services, June 2009”), Medicare beneficiaries spent an average of $4,394, or 37 percent of the individual beneficiary’s income, on health care costs. The oldest and poorest beneficiaries spent more than half their incomes on health care services.

•     Patients going on service for home health must pay a 20 percent copay and the Part B deductible to retain the services of a physician who can order the home health plan of care and provide care plan oversight.  They must pay a copay for home medical equipment.  Many home health patients will also incur the hospital deductible and copays and the skilled nursing facility copays before becoming eligible for the home health benefit.

•     With hospital and nursing home care, Medicare pays for room and board, as well as for extensive custodial services.  At home, these services are provided by family members or paid out of pocket by patients without family support.  Family members are frequently trained to render semi-skilled support services for home care patients, which Medicare would have to pay for in the hospital or nursing home setting.

 Copayments as a means of reducing utilization would be particularly inappropriate for home health care.

•     Since 1997, the average number of home health visits provided over a 60-day episode under Medicare has dropped from 36 to 18.  Spending on a per patient basis is no greater today than in 1997. Adjusted for inflation, Medicare spends billions less on home health care today than in 1997 and serves fewer Medicare beneficiaries. The home health benefit has dropped from 8.7 percent of the Medicare program to 3.7 percent, and CMS projects that it will drop to 3.5 percent by 2020.

 Imposition of home health copayments should not be used for deficit reduction or to pay for other initiatives.

•     The Balanced Budget Act of 1997 intended to reduce projected spending on home health services by $16 billion over five years.  Instead, home health outlays were reduced by more than $74 billion over the same time period and Medicare spending on skilled nursing facility care increased dramatically.

•     Since 1997, Medicare spending on home health care has consistently been billions below CBO projections.

Medicare supplemental coverage would not necessarily cover home health copays and would be too costly for most home care recipients.

•     Although 17 percent of Medicare beneficiaries purchase Medigap coverage and 34 percent have coverage from an employer sponsored plan, there is no assurance that these plans will cover a home health copay.  (Kaiser Family Foundation, 2009)  The law governing Medigap policies does not require that all models cover copays. Likewise, the 22 percent enrolled in Medicare Advantage (MA) plans would not be protected from a home health copay, as many MA plans have imposed home health copays even in the absence of a copay requirement under traditional Medicare.

Copayments would impose an unfunded mandate on the states.

•     About 15 percent of Medicare beneficiaries receive Medicaid.  Studies have shown that an even larger proportion (estimated to be about 30 percent by MedPAC) of Medicare home health beneficiaries—who are some of the oldest, sickest, and poorest beneficiaries—are eligible for Medicaid. (e.g. Mauser and Miller, “A Profile of Home Care Users in 1992,” Health Care Financing Review, Vol. 160, Fall 1994, p. 20.)  A home health copayment would shift significant costs to states that are struggling to pay for their existing Medicaid programs.

•     Even if Medicaid recipients with low incomes were exempted, a home health copay would cause more Medicare recipients to “spend down” to become eligible for Medicaid under the “medically needy” program.

Copayments would be another federal administrative burden on providers and would increase Medicare costs.

•     Home health agencies would need to develop new accounting and billing procedures, create new software packages, and hire staff to send bills, post accounts receivable, and re-bill.  Also, unlike hospitals, there is no provision for bad debt from uncollected copays currently built into the base payment for home health care.

•     Nurses and home care aides might be placed in the position of having to collect copays, a task for which they are unsuited.  They would have to carry large sums of money, increasing their exposure to robbery and muggings. Collecting copays in a person’s home is not like a hospital or physician’s office where clerical staff can handle billing and collection.


Background: In 1999, the United States Supreme Court held, in Olmstead v. L.C., that state Medicaid programs were required under the Americans with Disabilities Act (ADA) to undertake steps to support access to community-based health care options as an alternative to institutional care. Subsequently, the Bush Administration established its New Freedom Initiative, which has provided guidance to the states in developing Olmstead/ADA compliance plans. In addition, both the Bush and Obama administrations have voiced support for increased federal payments to assist states in transitioning Medicaid nursing facility patients into home care services. In some states, Medicaid has moved with reasonable and deliberate speed. In others, action seems nonexistent. One problem is the limits on valuable federal support for the administrative actions needed. Another problem is the pressure from institutional care providers to slow any progress towards home care alternatives.


The Deficit Reduction Act of 2005 (DRA), (Public Law 109-171) contains several provisions that rebalance Medicaid long term care coverage toward home care. These initiatives include a “Money Follows the Person Rebalancing Demonstration” through which individuals who are residing in institutions can be provided an opportunity to receive alternative home and community-based care. The provision makes grants and enhanced federal Medicaid payments available to incentivize states to compete for an award of the demonstration program. The enhanced federal payments can range as high as 100 percent of the cost of the home care for the first 12 months. The bill provided $1.75 billion in new federal payments to support the project.


DRA also included an optional benefit for Home and Community-Based Services for the Elderly and Disabled that allowed states to bypass the “waiver” process that includes requirements for proving the cost effectiveness of services. This benefit required that states establish more stringent standards for Medicaid payment of institutional care as one means of shifting patients to home care settings.


The DRA provisions, while evidencing the federal preference for rebalancing Medicaid long term care expenditures in favor of home care, also highlight support for self-directed care. Both provisions allow for, and even encourage, the availability of services through consumer-directed care models. However, these models are designed with quality assurance requirements, a patient need assessment requirement, and authority for the use of multiple delivery model types. The degree to which states are establishing and enforcing effective quality standards is less clear.


The Patient Protection and Affordable Care Act of 2010 (PPACA) incorporated several provisions that encourage greater utilization of home and community-based services under Medicare, including, under sections 2401-2406:


•     Establishment of the Community First Choice Option, which allows for enhanced federal matching for community-based attendant supports and services to disabled individuals up to 150 percent of federal poverty level who require an institutional level of care;

•     Extension of the Money follows the Person Rebalancing Demonstration program;

•     Protections against spousal impoverishment in Medicaid home and community-based services;

•     Enhanced federal matching through the State Balancing Incentive Program for select states to increase the proportion of non-institutionally-based long-term care services; and

•     New options for states to offer home and community-based services through the state plan for individuals with incomes up to 300 percent of the maximum supplemental security income payment who have a higher level of need and to extend full Medicaid benefits to individuals receiving home and community-based services under a state plan.

In recent years, as financial strains have beset federal and state governments alike, providers of home care services have raised concerns that while rebalancing efforts continue, payment levels fall far short of the cost of providing services. In addition, these financial strains have led a number of states to shift Medicaid beneficiaries into managed care plans for acute care services as well as long term care supports. The experiences with long term managed care create concern that the rebalancing of care away from an institutional setting and towards home and community-based care will be set back.

Recommendation: Congress should ensure that CMS properly implements the Medicaid home care expansion in PPACA and encourage states to embrace broader coverage of home and community-based services under Medicaid.

Congress should establish firm deadlines for Olmstead/ADA compliance with the penalty of lost federal financial matching payments for failure to meet the deadlines. Further, Congress should authorize an increase in the federal matching payment for expanded Olmstead/ADA-compliant home and community-based services, and 100 percent federal reimbursement for state Medicaid compliance costs in transitioning to improve home care alternatives.  The rebalancing of expenditures in favor of home care should be accomplished consistent with principles that:  1) establish Medicaid home care as a mandatory benefit in state Medicaid programs; 2) authorize care based on need; 3) assure quality of care through enforcement of comprehensive delivery standards; 4) provide the Medicaid client with a choice of care delivery models; and 5) ensure adequate reimbursement levels.

Congress should monitor carefully any shift of Medicaid beneficiaries into managed care and ensure that the patients’ rights to home care under the ADA and the Olmstead decision are fully secured.

Rationale: After several years, it is necessary for Congress to intervene and secure the systemic reforms guaranteed by the ADA.  However, states need financial support in these efforts since the transition will have start-up costs.  The rebalancing must be accomplished with federal minimum standards of care and access whether the state maintains a traditional fee-for-service care model or a managed care approach.








Home Care by the Numbers

Posted on: March 23rd, 2012 by accreditednursing

An at-a-glance guide on Medicare provided by National Association for Home Care & Hospice

The Relative Costs: All Medicare

$44: Average Medicare cost per day of a patient receiving home health care.

$559:  Medicare cost per day in a typical nursing home.

$1,932:  Medicare cost per day in a typical hospital stay.

The Medicare Cuts – Actual and Proposed: All Medicare

10:  Number of consecutive years CMS or MedPAC have proposed cutting Medicare Home Health

reimbursement rates. (Centers for Medicare and Medicaid Services and Medicare Payment Advisory


77 billion:  Affordable Care Act and Regulatory Action cuts over the next 10 years.

Nearly $1,120:  Deficit Commission yearly out of pocket co-pay for a year of home care.
The Beneficiaries: All payment models, including Medicare, Medicaid, CHIP, etc.

78 million:  Number of baby boomers. (Bureau of the Census)

10,000:  Number of boomers who retire each day starting in January of 2011. (Social Security


12 million:  The number of people who need home care and hospice each year. (National

Association for Home Care & Hospice)

The Economic Impact: All payment models, including Medicare, Medicaid, CHIP, etc.

Nearly 3 million:  The number of people employed in home care. (Bureau of Labor Statistics)

81:  Percentage growth in home care employment that the Bureau of Labor Statistics estimates will

take place between 2010 and 2020.

1: Rank of medical services in job growth among major economic sectors. (Bureau of Labor


Accredited marches to our Nation’s Capitol

Posted on: March 23rd, 2012 by accreditednursing






Barry Berger

Accredited Nursing Care

818.986.1234 ext. 101



Accredited staff members head to nation’s capitol to fight for the right of every American to be cared for

 in their home


WASHINGTON D.C. (March, 2012) – Accredited will join other members of the National Association for Home Care & Hospice on March 25-28, 2012, for the annual March on Washington & Law Symposium Conference & Exposition. Representatives from California will converge on Capitol Hill and execute their right to petition members of the Senate and House, with the goal to encourage Congress to protect and expand access to home care and hospice services for aged, infirm, disabled, and dying Americans.

The conference will be held at the Renaissance Mayflower Hotel and will address current hot topics in health care legislation, regulatory issues, technology, home care, private duty and hospice. This dynamic conference brings together hundreds of the nation’s home care and hospice providers – those on the front lines of caring for aged, ill and infirm Americans in the comfort of their own homes. Attendees will hear from more than 50 speakers and will earn continuing education credits for attending.

The focus of the conference includes key legislative priorities for 2012-among which are: Secure the strategic role Congress intends for home care and hospice in addressing the nation’s acute, chronic, and long term care needs; ensure appropriate and adequate reimbursement for and access to Medicare home health services; ensure appropriate and adequate reimbursement for and access to hospice services; protect and expand access to home and community-based services under Medicaid; and protect access to home care and hospice services, including for care paid directly by individuals.

“As Chairman of the California Association for Health Services at Home, I am looking forward to leading the California delegation as we meet with our congressional leaders regarding the issues involving the home care industry.  Our goal is to continue educating our elected officials regarding the unintended consequences of the elimination of the Companion Exemption,” commented Barry Berger, president and owner of Accredited Home Health Services.

Among the many highlights of the conference, was the opportunity to attend the Senate Breakfast and Briefing featuring some of the leading voices in Congress that have advocated for home care and hospice in recent years, including Senators Susan Collins (ME), Ben Cardin (MD), Tom Carper (DE), and Amy Klobuchar (MN) and Representatives Jim McGovern (MA) and Allyson Schwartz (PA).  Accredited also met with California’s own Senator Barbara Boxer, and Congress Members: Karen Bass, Adam Schiff,  Brad Sherman, Pete Stark and Henry Waxman to bring attention to the importance of home care and hospice.

 The annual march comes at a time when the Medicare home care benefit which was $17 billion in 2009 has been cut by $77 billion over the next ten years. As a result of these cuts about 50 percent of all Medicare participating agencies will be under water in 2012 — that is, paid less than their costs by Medicare, even though home care and hospice is more cost effective, saving billions in Medicare expenditures. Currently, the average Medicare cost for a patient to receive home health care is $44 per day, compared to $559 per day in a typical nursing home and $1932 per day for a typical hospital stay.

“Millette Arredondo, Michelle Hofhine, Neil Rotter and I, hope to achieve the same results and positive outcomes as we did last month in Sacramento,” added Berger.


About the Accredited Family of Home Care Services

Accredited was founded in 1980 by its current owner and president, Barry Berger.  For more than 32 years, Accredited has provided quality home care services, allowing the disabled, elderly and homebound to remain safe and comfortable at home.  Today, Accredited services thousands of patients from their five offices located in Woodland Hills, West Los Angeles, Pasadena, Costa Mesa, and San Diego.


About NAHC

The National Association for Home Care & Hospice (NAHC) is a nonprofit organization that represents the nation’s 33,000 home care and hospice organizations. NAHC also advocates for the more than two million nurses, therapists, aides and other caregivers employed by such organizations to provide in-home services to some 12 million Americans each year who are infirm, chronically ill, and disabled. Along with its advocacy, NAHC provides information to help its members provide the highest quality of care and is committed to excellence in every respect. To learn more about NAHC, visit


Heart to Heart: A bridge to transplants

Posted on: March 22nd, 2012 by accreditednursing

     During last Wednesday’s in-service, the Accredited field team of nurses, therapists, and social workers discussed a recently opened case of a heart patient.  The patient underwent a surgical implantation of the SynCardia temporary Total Artificial Heart (TAH-t) and was discharged once her condition stabilized.

     As the demand for donors’ hearts increase, its supply remained the same for the past 20 years.  At present, there is an estimated 2,200 donor hearts available in the U.S., according to a recent survey.  To meet this growing demand for transplants, the SynCardia TAH-t assists the process by prolonging the life of the patient and presents an alternate solution to the LVAD (Left Ventricular Assist Divide).  Once stabilized, a patient with the SynCardia TAH-t is moved to the top of the transplant list.

     The procedure involves the removal of the left and the right ventricles and the four natural valves of the heart, leaving the left and right atria, aorta, and pulmonary artery intact.  The surgeon then implants the TAH-t.  The device is powered by a vacuum-like device weighing more than 400 lbs.  Patients who undergo the procedure usually stay in the hospital for a certain amount of time.  However, upon discharge, the transplant patient is given something called a Freedom Portable Driver.  It’s usually carried in a backpack or a shoulder bag and weighs around 12 lbs.  A patient suffering from end-stage biventricular heart failure, a condition where both sides of the heart become weak and is unable to pump blood through the body, is usually the recipient of said transplant.  The current success rate of this procedure is very promising.

     To date, about 950 SynCardia TAH-ts have been successfully implanted worldwide.  According to SynCardia’s website, this is the only device that “provides immediate, safe blood flow through both ventricles to help vital organs recover faster.”

More information regarding the TAH-t can be found at

Part 7 – Revised Standards of Practice for Case Management: Duty to Implement Appropriate Plans

Posted on: March 22nd, 2012 by accreditednursing

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

Twitter: @HogueHomecare

E-mail: ElizabethHogueatElizabethHoguedotnet  (ElizabethHogueatElizabethHoguedotnet)  



Standards governing the practice of case management were first published in 1995 by the Case Management Society of America (CMSA).  The standards were revised for the first time in 2002 and again in 2010.  This is the seventh in a series of articles about the legal and ethical implications of the standards revised in 2010.


Deviations by case managers from applicable standards of care may result in legal liability.  More specifically, the standards of care published by CMSA make it clear that the role of case managers is to collaborate with clients and others to assess, identify, plan, and monitor health needs on an individual basis.  According to the Standards, case managers must use specialized skills to accomplish these goals, including development and implementation of appropriate case management plans.


When case managers fail to develop and implement appropriate case management plans, they may have legal liability for failure to do so.  In order to show that case managers are liable, patients must prove that: (1) case managers owed a duty to patients to develop and implement appropriate case management plans, (2) case managers breached this duty when they failed to do so, and (3) case managers’ failure to develop and implement appropriate case management plans caused injury or damage to patients.  All three of these requirements must be met.  If patients fail to prove even one of these requirements, they will lose their lawsuits.


Case managers owe a duty to patients to develop and implement appropriate case management plans.  The key question is: What is reasonable?  The law says that what is reasonable is what everyone else is doing.  Evaluations of what case managers are doing in a particular locale are not good enough, according to the law.  Rather, the law defines reasonableness based upon national standards of care.  What is reasonable depends, therefore, upon national standards of care for case managers.


Patients must also prove that case managers breached their obligation to develop reasonable plans.  There are two ways in which case managers can breach their duty.  They can, for example, do something that they should not do, i.e. an act.  They can fail to do something that they should have done, often referred to as an omission.  All patients must do is prove one act or omission on the part of case managers in order to hold them liable.


In addition, patients must be able to show that the case managers’ act or omission caused their injuries.  The best way to define causation is in terms of “but for.”  In other words, “but for” the act or omission of case managers, the patient would not have been injured.


Time is an important aspect of proof of causation.  The longer the period of time between the acts or omissions of case managers that patients claim caused their injuries and the actual damage or injury to patients, the less likely it is that case managers are liable.  The longer the period of time, the more likely it is that something else happened to cause the injury or damage to clients, which the law often calls an intervening cause.


Finally, clients must be able to demonstrate that the acts or omissions of case managers caused injury or damage to them.  What kind of injury or damage must patients demonstrate?  Is a showing of emotional injury alone, for example, enough upon which to base a determination of liability?  The “good news” for case managers is that courts usually require proof of physical injury or damage in order to hold them liable.  Patients’ claims that they have suffered emotional distress or were “harassed” are usually not enough to sustain a claim for liability of case managers.


In summary, clients may use the legal theory of negligence to attempt to hold case managers liable for failure to develop and implement appropriate case management plans.  If patients are able to meet the requirements for proof of negligence described above, case managers may be legally liable for this breach of applicable standards of care.





(For a copy of the book, Case Management: Legal Issues, send a check for $30.00 made out to Elizabeth E. Hogue to: Fulfillment, 107 Guilford, Summerville, SC  29483.)



© 2012 Elizabeth E. Hogue, Esq.  All rights reserved.


No portion of this material may be duplicated in any form without the advance written permission of the author.

Governor Proposes Cuts to Caregiver Centers

Posted on: March 14th, 2012 by accreditednursing

– HealthyCal –

Governor proposes cuts to caregiver centers

Program offers support services to those caring for relatives or friends with cognitive impairments

Though there are support groups for patients, like her husband, with Parkinson’s or other illnesses, the Del Mar Caregiver Resource Center is the only resource she found for herself, says JoAnn Martin, 75.

By Melissa Flores

Nearly 12,000 caregivers across California will feel the effects of Gov. Jerry Brown’s proposal to cut state aid to caregiver resource centers.

The cuts will touch the lives of women like Audrey, 77, who has relied on the Del Mar Caregiver Resource Center in Santa Cruz for the last five years. She cares for her husband, who has multiple sclerosis and is almost 81. She discovered Del Mar five years ago in what she describes as a period of crisis in their lives.

Audrey uses the center’s counseling services and the support groups. She’s taken classes at the Caregiver University, an annual workshop that counsels participants on issues like self-care and how to understand dementia or the other behaviors that results from the illnesses of their loved ones.

The current proposed budget calls for all state funding to be withdrawn from resource centers for a savings of $2.9 million statewide.

The proposed budget calls for a total of $10.3 billion in cuts for the 2012-13 fiscal year, with a revision due in May before the budget is enacted in June. Part of the budget hinges on proposed tax measures that could be on the state ballot in November.

There are 11 centers across the state that provide services to caregivers who are providing support to a family member suffering from a cognitive impairment or ailment, such as Alzheimer’s, dementia, a brain injury or a variety of other illnesses. Del Mar provides support to Santa Cruz, Monterey and San Benito counties.

“It’s one of the only agencies that helps caregivers,” Audrey said, adding that if the services were cut, she would have to continue to care for her husband at home on their fixed income. “It’s a very difficult situation. All the help you get is important.”

In the five years she’s used the services, they have been integral to helping her cope with the stresses of caregiving.

“When I went initially, I used the counseling and went to a spousal caregiver support group,” she said. “It was wonderful. I was really in need. It was a godsend.”

JoAnn Martin, 75, has been caring for her husband for the last three years. She heard about the caregiver support group from a friend. Her husband Gordon, 84, has Parkinson’s Disease. She said he started out with tremors and walked slowly at the initial onset of his illness. As it has progressed, he has had trouble swallowing and going to the bathroom.

“It just means so much,” Martin said, of attending the support group and sharing her concerns about the future. “I started back [to the support group] in September 2011 and in that time three women have lost their husbands. You get an advance [look at] the attitude of dealing with death.”

She said though there are support groups for patients with Parkinson’s or other illnesses, she said the Del Mar Caregiver Resource Center is the only resource she found for herself.

“To lose the funding of an agency that is so powerful at being able to reach out” would be troubling for some families, she said.

She added that she does not have a computer so it is difficult for her to find information from other sources so she relies on the support group and the Caregiver University events as a primary source of information.

Since her husband’s diagnosis, he has been hospitalized for an extended period and then released into her care on hospice. He went off hospice in April 2011 because his condition remained stable. After an attack of colitis in January, he has started physical therapy.

“I can get him up and set him in a wheelchair or set him in other chairs,” she said. “But it’s constant. I have not been able to hire help.”

Audrey can no longer meet her husband’s needs on her own. Del Mar provides funding that pays an aide to help her husband shower and gives Audrey a break from the house so she can run errands.

John Beleutz, the executive director of Health Project Centers, which oversees the Del Mar Caregiver Resource Center, sees the proposed cut as having a potentially drastic impact on the clients at the center.

“We know family caregivers are at high risk for mental and physical problems,” he said. “We try to alleviate that.”

He noted that when it comes to long-term healthcare, “it isn’t most people being in a nursing home. Most are at home being taken care of by family.”

Beleutz said the centers, created 30 years ago, have been a model nationwide.

“It’s been used in other places and it was really innovative when it came out.”

He said the centers saw a 72 percent cut to funding a few years ago, but the complete cut of state funding may lead some centers to close their doors. Others will have to drastically reduce services to stay open. He said the state funding is used to leverage other funding – from private donations, grants or the federal government – so the cut will hamper their efforts beyond the $2.9 million.

If the cuts go into effect, Beleutz foresees more caregivers moving loved ones into nursing homes.

“The annual cost of a nursing home is $74,000 a year – the national average,” he said.

Del Mar Caregiver’s center worked with 700 families last year.

“And there are many more we haven’t served, but we could if we had more funding,” he said.

Kathleen Kelly, the executive director of the National Center on Caregiving and the Family Caregiver Alliance, advocacy groups, said her agency estimates that family caregivers provide at least $8,000 in care each year. The amount of funding paid by the state is 50 cents per person.

“What’s kind of interesting is that this program was the first in the country to recognize family caregivers as the major workforce of long-term care and also to recognize and understand there are special stresses and needs of family and informal caregivers,” Kelly said. “It was signed by Jerry Brown when he was in office the first time.”

The pilot program began 30 years ago.

Kelly spoke on Feb. 23 before the California Assembly Select Committee on Disabilities in Sacramento urging legislators not to cut the funding to the program. She told legislators that more than 80 percent of the care for those who need assistance either due to a mental or physical disability are cared for by family, a friend or neighbor. There are 5.8 million informal caregivers in California, she said.

The state provides two-thirds of the funding for CRCs, but without the funding they would also lose matching funds of more than $10 million from the federal government under the Older Americans Act, which supports senior programs including the caregiver centers.

In an interview after the testimony, Kelly talked about the changing demographics in California.

“We’ve done this long-term development in a state that on a percentage basis may not have the largest percentage of older adults, but we certainly have the largest number,” she said. “The evolution is that there is less facility care and it is more community based. That is almost entirely predicated on having informal support in the community.”

Most of the caregivers are in their 40s or 50s and the majority of them are baby boomer women who are caring for parents or other aging family members, she said. Two-thirds of them work full or part time.

“They are providing 20 to 40 hours of assistance a week,” she said. “It increases if you have someone with cognitive impairments instead of just physical. They are really working two jobs.”

Like Audrey, many of the caregivers who use the Del Mar Caregiver Resource Center are supporting a loved one over the long term. Audrey’s husband was diagnosed with MS in the 1980s. He has not been able to work since a few years after he was diagnosed, so she said they did not have a lot of money in their retirement. Over the last five years, his health has declined rapidly. She described the experience as putting a frog in a pot of water and gradually bringing it up to a boil – she didn’t realize that she was feeling overwhelmed until it got to a point of crisis.

“It got to a point where it was really bad,” she said.

Kelly predicted it would be harder for caregivers without the support of the CRCs.

“If you cut stuff out at the community level, it gets much more difficult for families to juggle all these competing demands,” Kelly said.

Kelly said that the burden of caring for a loved one can be especially hard on middle income families that do not qualify for Medi-Cal.

“These are folks making under $50,000 as a household,” she said. “They can’t qualify for Medi-Cal and can’t afford to pay for services.”

The proposed 2012-13 budget can be viewed online [2].

Application of the FLSA To Domestic Service – Companion Care Exemption

Posted on: March 9th, 2012 by accreditednursing

Mary Ziegler, Director

Division of Regulations, Legislation and Interpretation

Wage and Hour Division

United States Department of Labor

Room S-3502

200 Constitution Avenue, N.W.

Washington, D.C. 20210

RE: Wage and Hour Division – (RIN) 1235-AA05

Comments on Proposed Rulemaking

Regarding Application of the FLSA to Domestic Service

Dear Ms. Ziegler:

I write to you today because my business, industry, employees, and most importantly, those we support are being put at risk by the notice of proposed rulemaking (NPRM) published by the Department of Labor’s Wage and Hour Division on December 27, 2011. This regulation would eliminate the companion care exemption for third party employers, and as a practical matter, makes it rarely usable by others due to the limits placed on personal care. It significantly changes Congressional intent and key components of the Fair Labor Standards Act which has been in place since 1974.

I oppose the NPRM because there is no demonstrable need for regulatory alteration, and the proposed changes will have a profound, adverse impact on fragile, aging seniors and people with disabilities. These changes would severely harm in-home care companies and their employees.

I believe these outcomes are likely consequences should this rule be enacted:

In-home non-medical care providers, like my company, will face increased costs as we would be required to pay overtime, especially to caregivers who work 24 hour or live-in jobs. This requirement, coupled with new burdensome reporting requirements, will encourage employers to limit caregivers’ hours to 40 hours a week, transition to a shift model for 24 hour or live-in care, thus drastically harming our clients’continuity of care.

As the costs of home care rise, 24 hour or live-in care will not be affordable. Those dependent on this service may be forced away from trained, insured, bonded, licensed in-home care providers, opting instead for unskilled workers in the underground “grey market.” Most of these workers will likely not comply with FLSA requirements, nor will they be able to navigate the complexity of the exemption. These independent employees often come without background checks and are uninsured; leaving families without recourse should a crisis arise.

If in-home care becomes economically unfeasible for families, a greater number of those in need of care could be more likely to utilize public programs, such as Medicaid, leaving taxpayers responsible for the cost of care.

Ultimately, small-business private duty home care employers, which are labor-intensive and low-margin operations, will be forced to modify their service model in ways that will not benefit those we serve in order to avoid incurring significant increase in costs.

As an in-home care provider, my employees and I see firsthand how hastily-made regulations and laws can leave seniors without the support they need and can create unneeded expenses families can ill afford.

In short, the NPRM will significantly increase in-home non-medical costs. The changes will ultimately lower pay for caregivers, harm continuity of care, threaten the economic viability of private duty companies, increase federal spending on government
programs, create a significant loss of federal and state revenue, and incentivize an underground “grey market,” populated by untrained, unsupervised, and unregulated caregivers for whom taxes are not paid.

For these reasons, I urge the DOL to withdraw this NPRM due to the harm it will cause to those who need in-home care, the caregivers who provide it, the companies that employ those caregivers, and the taxpayers who pay for government-subsidized long-term care.


Neil Rotter, MSG, MSW


Time to Talk to Your Parents About the Future

Posted on: March 8th, 2012 by accreditednursing

What happens when we suddenly become the
caregivers… When it’s suddenly our turn? America’s growing generation of Baby
Boomers now faces a challenge they were never prepared for: Taking care of
ailing or aging loved ones. In this new documentary series produced by KCET,
host Holly Robinson Peete takes viewers on journeys into this often
heart-wrenching passage of life exploring the overwhelming challenges faced by
caregivers of every ilk. Four half-hour episodes focus on different families
who find themselves at an important stage along the caregiving path, offering
viewers solutions and hope through inspiring stories and a multitude of
resources. Robinson Peete, an acclaimed actress and award-winning author, also
shares her own experiences of caring for her father who had Parkinson’s



Hearing to Review Consequences of Labor Department’s Companion Care Regulation

Posted on: March 8th, 2012 by accreditednursing

WASHINGTON, D.C. | March 5, 2012 –

On Wednesday, March 7 at 10:00 a.m., the Subcommittee on Workforce Protections, chaired by Rep. Tim Walberg (R-MI), will hold a hearing entitled “Ensuring Regulations Protect Access to Affordable and Quality Companion Care.” The hearing will take place in room 2175 of the Rayburn House Office Building.

In 1974, the Fair Labor Standards Act was amended to cover workers who perform domestic services. At the time, policymakers recognized the need for seniors and individuals with disabilities to maintain access to affordable care in their home. As a result, Congress created an exemption for workers providing in-home companion care. Yet, a regulatory proposal released last year by the Department of Labor would severely restrict a worker’s ability to qualify for this exemption, with potentially negative consequences for individuals who rely upon these services.

Under the department’s proposal, only workers who comply with a number of arbitrary standards would qualify for the exemption. The proposed regulation also eliminates the exemption for companion care workers employed by a third-party. According to the department’s own estimates, the cost of companion care may increase anywhere from $420 million to $2.26 billion over the first 10 years.

Wednesday’s hearing will provide members an opportunity to examine the potential consequences of this proposal, including fewer hours of work for employees; higher costs for taxpayers, seniors, and individuals with disabilities; and fewer opportunities to receive in-home care. To learn more about this hearing, visit

Undercover 82-year old Grandma exposes Home Health Fraud in Texas

Posted on: March 1st, 2012 by accreditednursing

I guess Medicare wasn’t listening when Texas proudly proclaims, ‘Don’t Mess with Texas’.  Here’s another tragic bad apple in the home care community.

In the wake of an ABC News undercover investigation, federal authorities in Texas are investigating how an active 82-year-old grandmother was diagnosed as homebound, with a range of ailments that she did not have, including Type 2 diabetes, opening the door to potentially tens of thousands of dollars in Medicare payments for home health care, supplies and equipment she did not need.

A hidden camera recorded the undercover grandmother’s visit to a doctor in McAllen, Texas, where she told the doctor and nurses she exercised regularly and, other than some hypertension and arthritis, was in excellent health.

“I’ve really enjoyed good health all my life, God’s been good to me,” the doctor was told by Doris Ace, the grandmother of ABC News producer Megan Chuchmach.

Yet the official certification sent to Medicare for home health care services indicate she was homebound and suffered from two internal infections, incontinence and needs “assistance in all activities, unable to safely leave home, severe sob,” an abbreviation for shortness of breath.

Mrs. Ace had specifically told the doctor and her nurses she did not suffer from incontinence or shortness of breath.

On a patient referral form for home health care service, signed by the doctor, our undercover grandmother was also wrongly diagnosed with type 2 diabetes, even though she was not given a blood test which doctors say is the only way to authoritatively diagnose diabetes.

The overall diagnosis of the undercover grandmother’s health could have provided the justification for what could be tens of thousand dollars a year worth of unneeded treatment and medical supplies and equipment,  federal investigators said in an interview to be broadcast tonight on ABC News’ “World News with Diane Sawyer” and “Nightline”.

“That’s fraud,” said Tim Menke, senior adviser for investigations in the Inspector General’s office at the Department of Health and Human Services.

“Our Medicare system is an honor system,” said Menke after viewing the files and the ABC News undercover tape of the doctor’s office visit. “And there’s not much honor left in the system when you see things like that.”

McAllen is considered a hotbed of Medicare fraud by the Inspector General’s office which has already brought cases against a number of doctors and health care agencies and has many others under investigation.

“The fraud indicators are off the charts,” said Menke of McAllen and surrounding towns in the Rio Grande Valley. “We have ten of the top physicians who have billed nearly $200 million in one specialty last year alone.”

Nationwide, the Inspector General’s office estimates that $60 billion dollars of taxpayer money is lost to unchecked Medicare fraud every year.

“We’ve seen it in Miami, Detroit and now in McAllen and it’s very, very common,” he said.

“They’re lying in order to steal from you and me and the taxpayers,” he added.

The McAllen doctor, Dr. Padmini Bhadriraju declined to comment to ABC News but denied any wrongdoing through her lawyer.

The lawyer, John Rivas, said the doctor acknowledged an “error” in the diabetes diagnosis for ABC News’ undercover grandmother on the patient referral form but said, “this section was filled out by someone other than Dr. Bhadriraju,” even though he confirmed the doctor did fill out the majority of the form and signed it in her handwriting.

Her signature served as certification that “my clinical findings support that this patient is homebound.”

The doctor’s lawyer said neither the doctor nor others in her office knew who filled in the incorrect diabetes diagnosis.

Rivas also said the doctor played no role in the official certification form sent to Medicare, although records show she billed Medicare for the review of the form and its plan of care.

“The records provided by ABC News do not support any allegations of fraud. It would be irresponsible journalism to air a story on Medicare/Medicaid fraud using this referral as an example when there is clearly no evidence of fraud,” he added in a letter to ABC News.ABC News ended the undercover investigation before any medical supplies or equipment could be billed to Medicare  based on the false diagnosis.

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