A Louisiana man was sentenced on December 13, 2023, to three years in prison for his role in a multi-year scheme to bill Medicare and Medicaid for medically unnecessary durable medical equipment (DME).
According to court documents, from approximately January 2016 through June 2022, the defendant billed Medicare and Medicaid for DME that was medically unnecessary. That included equipment for respiratory support and nutritional support, including ventilators, tracheostomy supplies, and feeding tubes. In reality, those items were medically unnecessary, not ordered, or not provided as represented. In some instances, the patients had already died.
The defendant billed Medicare and Medicaid approximately $11.4 million in connection with this scheme, and his company was reimbursed over $7.9 million. He personally obtained over $3.4 million in proceeds, which he used to pay for personal vehicles, personal chef services, events, and entertainment.
To cover up his scheme, the defendant directed the falsification of documents, including medical records, order forms, and supporting documentation, in response to Medicare audits and record requests. The falsification of documents included forging provider signatures, medical notes, and dates, as well as using tape, white-out, and scissors, to make it falsely appear that the audited DME was ordered and delivered.
Compliance Perspective
Issue
Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate. One of the most important steps a provider can take is to have a robust internal audit program that monitors and reviews claims. If a provider identifies billing mistakes in the course of those audits, the provider must repay overpayments to Medicare and Medicaid within 60 days to avoid False Claims Act liability. Staff should also understand their responsibility to identify and report concerns of utilization of any services that they believe are unnecessary or inappropriate for a resident, to include ordered tests, procedures, treatments, therapies, and medications.
Discussion Points
- Review your policies and procedures on ensuring that all provided resident services are reasonable and necessary and for prevention of false claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all 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. Ensure appropriate staff monitor for potential false claims related to unnecessary or inappropriate services that are unsupported by documentation. 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 document in each employee’s education file.
- Periodically audit medical records to ensure that all services provided to residents are reasonable and necessary. Also periodically audit to ensure staff are aware of compliance and ethics concerns and understand their responsibility to report any potential violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
