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Providers v. UPICs and ZPICs: Another Chapter

Simply Home Health Care, a home health agency in Illinois, is suing the U.S. Department of Health and Human Services (HHS) and AdvanceMed, a UPIC, for continued suspension of payments from the Medicare Program in Simply Home Healthcare, LLC . Azar et al, Case No. 1:19cv-02313 in the U.S. District Court for the Northern District of Illinois. Simply Home Health Care filed a class action lawsuit in the U.S. District Court for the Northern District of Illinois on April 5, 2019. Payments to the Agency were originally suspended because of an overpayment. The Agency was later told by AdvanceMed that payments were suspended because of suspected fraud. The Agency says that AdvanceMed cannot support its claims of fraudulent conduct.

The suspension of payments from the Medicare Program was ultimately reversed many months later. According to AdvanceMed, however, the Agency owed the Medicare Program $5.4 million. The amount due to the Medicare Program was later reduced to $4.8 million. Based on the alleged overpayment, Simply Home Health Care was forced to go out of business in 2017.

The Agency claims that AdvanceMed did not correctly apply federal statutes and regulations. Simply Home Health Care also claims that AdvanceMed had incentives to do so in order to win additional contracts from the Centers for Medicare and Medicaid Services (CMS). The Agency also claims in its suit that many other agencies have experienced the same fate as it did and deserve to be compensated for their losses, too. The Agency, therefore, filed a class action on behalf of both itself and these other agencies.

This case is another “chapter” in the continuing saga of providers v. UPICs and ZPICs. So far, the results of these efforts have been mixed. In some instances, providers have been able to obtain temporary restraining orders (TROs) from sympathetic judges that prevented recoupments until after hearings by Administrative Law Judges (ALJs). The courts in Texas, for example, have been especially receptive to providers’ requests for assistance with huge overpayments. In other similar instances, however, Courts have been unwilling to provide any assistance to providers even though providers continue to go out of business because of extrapolated overpayments and their inability to financially withstand massive recoupments.

Faced with the loss of their businesses, providers must, of course, continue to seek assistance from the Courts. The stakes are high! Consequently, providers must continue to “knock at the door” seeking relief from devastating actions by the UPICs and ZPICs.

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