The Department of Justice (DOJ) reported on November 17, 2022, that a federal jury convicted an Illinois woman for conspiring to defraud Medicare of over $6 million. According to court documents and evidence presented at trial, the woman worked as an unlicensed medical assistant for a physician in Chicago and surrounding areas from at least 2009 until at least 2012. In this position, she conspired with others, including the owners of two home healthcare companies, to fraudulently certify Medicare beneficiaries for home health services for which those beneficiaries did not qualify.
Specifically, the woman forged her physician employer’s signature on certification forms and supporting documentation, which caused Medicare beneficiaries to be enrolled in over 2,000 episodes of home healthcare at two Illinois home health agencies. She provided the forged physician forms to the two agencies, which enabled them to submit claims to Medicare for services that the beneficiaries did not need and were not qualified to receive. The owners of the agencies paid the woman kickbacks in exchange for the forged physician forms. The agencies received over $6 million from Medicare due to the woman’s fraudulent conduct.
The FBI and Department of Health and Human Services – Office of Inspector General (HHS-OIG) Chicago Regional Office investigated the case, which was brought as part of the Chicago Strike Force, supervised by the Criminal Division’s Fraud Section and the US Attorney’s Office for the Northern District of Illinois.
The Fraud Section leads the Criminal Division’s efforts to combat healthcare fraud through the Health Care Fraud Strike Force Program. Since March 2007, this program, comprised of 15 strike forces operating in 24 federal districts, has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in healthcare fraud schemes. More information can be found at https://www.justice.gov/criminal-fraud/health-care-fraud-unit.
Compliance Perspective
Issue
Ordering and billing for services a resident does not receive or that are not medically necessary can be seen as fraudulent billing or submission of false claims. It is illegal to submit claims for payment to Medicare, Medicaid, and private insurance that you know or should know are false or fraudulent. Falsification of signatures and other documentation is a crime. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Also, under federal and state Anti-kickback Statutes, you may not knowingly and willfully offer, pay, solicit, or receive anything of value to induce or reward for referrals of federal or state healthcare program business. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures on accuracy of documentation and on determining if services for patients are necessary. Also review policies and procedures for identifying and preventing illegal kickbacks and reporting false claims.
- Train appropriate staff on how to determine each resident’s level of care and if services provided are reasonable and necessary. Also train all staff on federal and state anti-kickback statutes and what can be considered an illegal kickback. Include information on how to report concerns and suspected violations, and make sure staff know that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit to ensure that documentation demonstrates medical necessity for all claims being submitted and that services have been approved by the resident’s primary physician or appropriate designee. Survey professional staff on their knowledge of what can be considered medical necessity. Also periodically audit staff understanding to ensure that they are aware of what should be done if they suspect a false claim has occurred, whether intentionally or unintentionally. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim. Immediately address any negative findings.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
