Fil-Am home health care CEO sues Medicare auditor and Health Sec. Price

MedPro Health Provider, LLC staffers in a photo early last year before a Medicare auditing company ordered a stop on its Medicare reimbursement, causing a massive layoff in the company. PINOY/Anong

CHICAGO—Rizaldy Villasenor is proud that his Tinley Park-based agency, Medpro Health Provider LLC, was named by the Chicago Tribune as one of the top workplaces in the area—not once but twice in a row. He founded his company with well-vetted partners in 2011, using his experience with the giant health care corporation and Ohio-based Cardinal Health.

A week after being recognized again by the Tribune last November, a Medicare subcontractor, AdvanceMed, slapped his company with an audit and determined improper payments had been made and Villasenor’s firm would no longer receive Medicare reimbursement.

The negative impact on his heath care business was immediate. Many of his patients had to be discharged before the end of 2016. Most of his employees were laid off by early January this year. His company is surviving with a skeleton staff – only due to his foresight in accepting managed care patients — those not dependent on Medicare payments.

Boilerplate response

AdvanceMed, a Medicare auditor known as a Zone Program Integrity Contractor (ZPIC), told Villasenor, CEO of MedPro, that he would have a chance to respond to the allegations of overpayments. He responded quickly. He rushed to submit a nearly100-page rebuttal statement, highlighting patients that were used as examples by the auditors. He also included supplemental documents from his MedPro doctors.

AdvanceMed quickly responded later in December. “It was a ‘general boilerplate’ response,” said Villasenor who doubted whether the ZPIC had actually reviewed the documents.

Villasenor  noted the short turnaround and lack of specificity in the response. In a later teleconference with auditors of AdvanceMed, Villasenor specifically asked if they reviewed his rebuttal, and the curt response was, “Why should we?” Villasenor believes that is a violation of due process—an important feature of this country’s jurisprudence.

Villasenor notes that “The ZPIC companies are not liable for lawsuits…that’s why they use Gestapo techniques, because they think they are immune to lawsuits. …What we have found out is that they are only not liable if they follow the due process in the guidelines. That’s why we have a case. Our lawsuit says they did not follow the process.”

Class Action

On April 11, 2017, Villasenor’s company sued Secretary of the Department of Health and Human Services (HHS) Tom Price and AdvanceMed for not following Medicare’s procedures related to the audit. MedPro is going after $300,000 it says it is owed in payments.

Health and Human Services Secretary Tom Price. AP

A hearing was held April 17 and a continuance was set for May 30. The news of MedPro’s court suit attracted the attention of home health care companies all over the United States. “About 40 firms who went through same experience as we did are willing to join our company that might result in a class action suit,” said the MedPro executive.

Villasenor expects the defense lawyers to move for a dismissal of his lawsuit, but his lawyer, Mike Raiz, believes MedPro has a strong case. “My employees also believe that we’ve done nothing wrong. We have nothing to hide…that’s is why I welcomed the demand for an audit,” Villasenor added.  “[With an audit], you feel a little scare or threatened…Right now, it’s anger that I am feeling. We were once ranked the No. 1 workplace. The worst thing is letting the team go because of this. If I’m going to close the company, I say it won’t be this way.”

Home health care, which used to be a flourishing business among Filipino Americans, has seen re-entrenchment in the last few years due to restrictions in Medicare reimbursement.

A number of owners faced federal charges of fraud and some were convicted and jailed. But a number of home health care companies actually received commendations for their efficiency and integrity in caring for their patients. Many closed their operations because they went through improper audits that were not challenged.