An owner of a Texas home health company was ordered to serve a 45-month prison sentence to be immediately followed by one year of supervised release for his conviction of conspiracy to commit healthcare fraud. He was also ordered to pay $1,037,353.78 in restitution. In handing down the sentence, the judge noted the lengthy duration of the fraud and the multiple ways in which the fraud was committed.
As part of the owner’s guilty plea, he admitted he submitted false and fraudulent claims to Medicare for reimbursement of home health services that were not provided, that a physician had not authorized, and/or were not medically necessary. The false and fraudulent claims he submitted to Medicare totaled $724,056.02. As a result of the false and fraudulent claims, Medicare paid approximately $1,037,353.78.
The owner further admitted he paid illegal kickbacks in exchange for patient information, including patient Medicare numbers. He and/or his co-conspirators would then use the fraudulently obtained Medicare numbers to submit claims to Medicare in order to receive reimbursements.
As part of his plea, the owner admitted he forged and/or caused others to forge the signatures of physicians on the referral forms or 485 forms, knowing the physicians did not authorize the need for home health services and/or that the beneficiaries did not need or qualify for home health services. He directed employees to create “ghost notes” for patient files which were intended and calculated to make the fraudulent claims submitted to Medicare appear legitimate. He also admitted that he directed employees and/or co-conspirators to bill Medicare for home health services with 485 forms which were missing physician signatures.
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. Under federal and state Anti-kickback Statutes, you may not knowingly and willfully offer, pay, solicit, or receive anything of value to induce or reward for referrals of federal or state healthcare program business. The prohibition against kickbacks applies to those who pay for referrals and to those who receive them. Kickbacks can take various forms, such as bribes or rebates. They can be given in cash or in kind. Failure to promptly report a kickback can result in lawsuits, fines, and other sanctions.
Discussion Points
- Review your policies and procedures for preventing and reporting false claims and kickbacks and for conducting a Triple Check Process to verify accuracy of Medicare 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 or kickback. Include information on how to report concerns and suspected violations, and make sure staff know that prompt reporting is mandatory. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare 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.*
