On May 15, 2024, US District Judge Lance Africk sentenced a hospice owner to 240 months of imprisonment, three years of supervised release, and $2,300 in mandatory special assessment fees, in relation to an extensive healthcare fraud scheme.
The defendant owned and oversaw the day-to-day operations of a hospice facility with offices in the New Orleans area, Baton Rouge, Covington, and Gulfport, Mississippi. At sentencing, the Court found that between January 2013 and December 2019, the defendant billed Medicare approximately $84 million in fraudulent claims and was paid approximately $42 million relating to these fraudulent claims. The Court ordered that the defendant repay the $42 million of fraudulent proceeds back to Medicare.
On November 6, 2023, a jury convicted the defendant on all 23 counts of healthcare fraud charged in the indictment relating to overbilling for hospice patients for expensive General Inpatient (“GIP”) services and for multiple counts related to manipulating Medicare billing codes, known as Common Procedural Terminology (“CPT”) codes despite such services being medically unnecessary, or despite their inclusion in the daily hospice benefit the company already received for its patients.
“Today’s sentencing signals the end of a long, complicated, and challenging prosecution,” said US Attorney Duane A. Evans. “However, this conclusion exhibits our commitment to fighting healthcare fraud in our district. Our office, along with our investigative partners, will continue to work diligently to preserve taxpayer confidence in our medical institutions and seek justice for all victims of fraud.”
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. 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. All medical services that are provided must be medically necessary, and the patient or resident must be eligible for the services that are provided and involved in the decision to choose those services. 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 for following standards of care and requirements for accurate documentation. 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. A program titled Liability of Fraudulent Documentation is available for all clients in the Fraud, Waste, and Abuse Category of Med-Net Academy.
- 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. Periodically audit to ensure that residents enrolled in hospice programs meet eligibility criteria, and that documentation is sufficient to support the need for hospice services.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
