A clinical social worker admitted to a federal judge that she helped devise and execute a scheme that shortchanged Rhode Island and Massachusetts substance abuse disorder patients out of counseling and treatment services while, at the same time, defrauding Medicare, Medicaid, and other health insurers out of more than $3.5 million dollars, announced United States Attorney Zachary A. Cunha on November 9, 2023.
The defendant, 63, admitted that, while employed as a supervisor at an addiction treatment center in Providence, she and others working at her direction routinely submitted false and fraudulent claims for psychotherapy and counseling services that did not occur for the length of time billed, and consistently billed for far more patients than was possible for staff to have seen during office hours. The defendant was known at the center as the “5 Minute Queen” for her speed in seeing patients for so-called counseling sessions. She admitted that while billing for 45-minute sessions she actually saw patients for no more than 5–10 minutes, at times asking patients only one question before she ended a session.
According to information presented to the court, to facilitate this fraud, the defendant directed counselors and others at the treatment center to record in their notes that they were providing counseling in 45-minute intervals, but without listing AM or PM for the start time. The defendant gave this instruction so that it was not clear that they were seeing more patients than possible within a single hour. She also instructed other counselors to copy and paste the last visit’s note into each entry to make the bill look complete. As a result, many of the patient notes for patients billed by the treatment center were identical cut-and paste copies of the same note.
The defendant pleaded guilty to a charge of conspiracy to commit healthcare fraud, and is scheduled to be sentenced on February 15, 2024.
Compliance Perspective
Issue
Healthcare fraud can be committed by medical providers, company owners, patients, and others who intentionally deceive the healthcare system to receive unlawful benefits or payments. 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. The OIG strongly encourages nursing facilities to have comprehensive procedures in place to ensure that services are of an appropriate quality and level and are in fact delivered to nursing facility 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 all staff on what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of their responsibility to identify compliance and ethics concerns and to promptly report violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Perform Triple Checks for all Medicare Part A claims prior to submission to ensure that medical necessity is supported by appropriate documentation, and that services meet skilled care requirements.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
