On March 8, 2024, Pennsylvania Attorney General Michelle Henry announced that a Philadelphia man was found guilty of Medicaid fraud and related crimes. The defendant falsely claimed to have provided home care services, causing the Medicaid program to pay over $4,200, even though the patient was actually in the hospital.
The defendant, 30, was convicted of four counts of Medicaid fraud, four counts of tampering with public records, and theft by deception — all felonies. He will be sentenced on a date to be determined in May.
The Office of Attorney General investigation revealed that the defendant had reported that he provided services during dates and times when the patient was hospitalized at three different hospitals. He submitted those hours to a Philadelphia-based home care agency, causing the agency to seek reimbursement from a Medicaid-funded managed care organization.
In total, the defendant claimed at least 262.5 hours he could not have performed, for which Medicaid paid out at least $4,297.74.
“Prosecuting these crimes is vital to maintaining the integrity of a healthcare system that helps Pennsylvanians receive care,” Attorney General Henry said. “This defendant intentionally defrauded the system and is now held accountable thanks to the tenacious work of our investigators and prosecutors.”
Compliance Perspective
Issue
Honesty, accuracy, and integrity are imperative for the provision of safe and effective healthcare. Falsification of documents regarding care, incomplete or inaccurate documentation of care, failure to provide the care documented, or other acts of deception or omission raise serious concerns about an individual’s ability to provide safe healthcare. Falsified documentation and misuse of allocated public funds can be seen as fraud, waste, and abuse of government funds. The Centers for Medicare & Medicaid Services (CMS) requires skilled nursing facilities to have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care.
Discussion Points
- Review your policies and procedures for following standards of care and requirements for accurate documentation. Also review your policies and procedures for operating an effective compliance and ethics program. Update as needed.
- Train appropriate staff on your policies and procedures for following standards of care, accurate documentation, and meeting regulatory requirements. Also train all staff on your compliance and ethics policies and procedures upon hire and at least annually, including their responsibility to identify and report any concerns of fraud, waste, or abuse of government funds in a timely manner.
- Periodically audit medical records and timesheets to ensure that documentation is complete, meets standards for content and timeliness, and that entries have not been falsified or erroneously reported in any way.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
