A physician from Edwardsville has pleaded guilty to a federal healthcare fraud charge. The charges stem from falsely documenting services provided to nursing home residents for reimbursement from Medicare. The US Attorney’s Office for the Southern District of Illinois made the announcement on March 6, 2024.
According to court documents, the defendant, a licensed physician employed by a medical practice, worked at various nursing home locations throughout the Southern District of Illinois. He was an enrolled provider in the federal Medicare program.
The defendant misrepresented services in medical and progress notes. These misrepresentations included listing services he did not perform, and also claims related to residents who were already deceased at the time of billed services.
Through the medical practice, the defendant submitted false claims to Medicare totaling more than $20,000 for health services he did not provide from October 2016 through September 2018.
The defendant’s sentencing is scheduled for June 5. Healthcare fraud carries a potential penalty of up to 10 years’ imprisonment, a fine of up to $250,000, and up to three years’ supervised release. Additionally, he must make restitution for government losses.
Compliance Perspective
Issue
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. 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. Nursing homes should have comprehensive procedures in place to ensure that services are of an appropriate quality and level and are in fact delivered to residents as ordered and as reported in claims for reimbursement. Moreover, accurate documentation at the time of service is critical to ensuring that billing is fully supported. 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 policies and procedures for preventing and reporting false claims and suspicious billing practices. Update your policies and procedures as needed.
- Train staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
