News Boston Home Health Company to Pay $1.95 Million to Resolve Allegations of Billing Medicaid for Unauthorized Services

Boston — A Boston-based home health care company will pay $1.95 million to resolve allegations that it filed claims for payment with the state’s Medicaid program (MassHealth) for services that were not certified as medically necessary, Attorney General Maura Healey announced today.

Guardian Healthcare, LLC will pay $1.95 million to resolve allegations it submitted claims to MassHealth for home health services that had not been appropriately authorized by a physician.

 “Home health care companies provide important services to people all across Massachusetts,” said AG Healey. “In order to maintain the integrity of the program, it is critically important that MassHealth providers keep accurate records and bill only for services that are medically necessary.”

 In order for a home health agency to bill MassHealth for home health services, a member’s physician must review and sign a plan of care certifying that home health services are medically necessary. Home health agencies are required to maintain these records for at least six years after the medical services are provided and claims have been made. The AG’s Office alleges that from April 2010 through July 2016, Guardian failed to obtain and/or maintain plans of care authorized by a physician for certain patients.

In addition to the financial settlement, Guardian has also agreed to implement a multi-year, independent compliance program which will involve updating its policies and procedures, training its staff, and conducting annual audits to ensure compliance with federal and state regulations.  

This settlement is part of a larger effort by the AG’s Office to combat fraud in the home health program. In April 2019, two home health care companies paid over $10 million to resolve allegations that they billed MassHealth for unauthorized services. In August 2018, a jury convicted the owner of a Boston home health care agency on seven counts in connection with a scheme to steal millions from MassHealth. In May 2019, a jury convicted the owner of a home health agency on five counts in connection with schemes that defrauded MassHealth of approximately $2.5 million. The home health agency, which had previously had offices in Dracut and Worcester, was also convicted.

 This matter was handled by Assistant Attorney General Stephany Collamore, Investigations Supervisor Dean Bates, and Investigators Ruth Zeltzer and William Welsh, all of the AG’s Medicaid Fraud Division. MassHealth and the Department of Health & Human Services, Office of the Inspector General provided critical assistance in this case.