A federal jury recently found a Chicago woman guilty of one count of conspiracy to commit healthcare fraud and wire fraud related to her role in a scheme to defraud Medicare of approximately $7 million between 2011 and 2017.
Evidence presented at the trial showed that the defendant conspired with the owner of the home healthcare company to submit claims to Medicare for unnecessary home health services for unqualified patients, or for visits that did not happen as billed. The defendant, in her role as an employee of the company and the personal assistant to the company’s owner, created and completed visit notes and other documents seeming to reflect nursing services supposedly rendered by the owner, although she knew the owner was not providing those services. She was also aware that the owner was making illegal cash payments to patients.
Three other defendants have also been charged in the fraud scheme. The owner, his spouse, and a former nurse have all pleaded guilty to conspiracy to commit healthcare fraud, and the owner also pleaded guilty to wire fraud. They and the defendant are currently awaiting sentencing.
Compliance Perspective
Knowingly participating in the submission of false claims to Medicare for reimbursement of services not provided or provided to unqualified Medicare beneficiaries, and ignoring and not reporting the payment of illegal kickbacks may result in being found guilty of violating the federal False Claims Act and Anti-Kickback Statute.
Discussion Points
- Review policies and procedures that are in place to prevent violations of the False Claims Act and the Anti-Kickback Statute.
- Train staff to know how to verify that documentation (i.e., nurse’s notes) supports legitimate submitted claims, that services were provided, and that beneficiaries were eligible. Also, train staff on how to report to their supervisor or through the Hotline any suspected incidents that might indicate fraud is occurring or individuals are being illegally paid for access to their personal identifying information.
- Periodically audit submitted claims to verify the accuracy of the documentation used to support those claims.
FOR MORE INFORMATION ON THIS TOPIC: FRAUD MODULE 3 – MASTERING LEGAL IMPLICATIONS AND ANTITRUST LAWS
