Vanessa Roberts Avery, United States Attorney for the District of Connecticut, announced on December 19, 2023, that a 72-year-old man was sentenced to 27 months of imprisonment, followed by three years of supervised release, for operating a $2.6 million healthcare fraud scheme. He was also ordered to pay restitution of $2,651,294.
According to court documents and statements made in court, the defendant, a licensed psychologist, and his wife, who is also a psychologist, maintained separate medical practices out of their home office in Old Greenwich. They were authorized providers for the Connecticut Medicaid program, Medicare, and other healthcare benefit programs. The defendant assumed responsibility for submitting claims for reimbursement for services allegedly provided by himself and his wife, both at their home office and at various skilled nursing facilities within Connecticut.
For years, the defendant billed insurers for services that he knew were not rendered, including by billing for patients who were deceased, for dates of service when he was out of the country, for dates of service when his wife was out of the country, and for dates of service when he was hospitalized. From 2014 through 2019, he submitted more than 80,000 claims for service, and he claimed to have provided services every single day, including weekends and holidays, except for one day in 2017. On 60 of these dates, the defendant billed for more than 24 hours of service, and on 901 dates, he billed for more than 12 hours of service. These fraudulent claims resulted in a loss of over $2,651,294, including a loss of $1,157,292 to the Connecticut Medicaid program and a loss of $119,092 Medicare.
Previously, in 2002, the defendant had settled a federal civil lawsuit alleging healthcare fraud, which was brought by the government in the Southern District of New York. He agreed to pay $4 million in restitution and was excluded from participating in all federal healthcare programs, including Medicare and Medicaid, for five years.
On December 12, 2022, the defendant again pleaded guilty to healthcare fraud. He is required to report to prison on March 25, 2024.
In May 2023, the defendant’s wife entered into a civil settlement agreement with the federal and state governments in which she agreed to pay $658,294 to settle allegations that she received payment for claims submitted by her husband to the Medicare and Medicaid programs for psychology services that she had allegedly provided to Medicare and Medicaid beneficiaries that were, in fact, not provided.
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. 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. Nursing homes should have comprehensive procedures in place to ensure that services are of an appropriate quality and level and are in fact delivered to 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 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. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
