Kusserow’s Corner: Highlights of December Enforcement Actions, Part 1

Miami Home Health Fraud

Two patient recruiters who worked for Miami home health agencies Good Quality Home Health Care Inc. and Caring Nurse and Good Quality were sentenced to prison and order to pay millions in restitution for their participation in a $48 million Medicare fraud scheme. They solicited and received kickbacks and bribes from the owners and operators of home health agencies in return for allowing the agency to bill the Medicare program on behalf of the recruited patients for services that were medically unnecessary and/or not provided. In a related case in February, the owners and operators of home health agencies were sentenced to serve to prison.

Another patient recruiter working for Caring Nurse Home Health Corp. in Miami was sentenced to serve 108 months in prison and ordered to pay $24 million in restitution, jointly and severally with co-defendants, for his participation in a $48 million home health Medicare fraud scheme. The recruiter solicited and received kickbacks and bribes from the owners who billed the Medicare program on behalf of the patients for home health care and therapy services that were medically unnecessary and/or not provided. The same patient recruiter also pleaded guilty to his involvement with fraudulent billings for Nation’s Best Care Home Health Corp. that also submitted fraudulent billings for approximately $30 million. The two owners and operators of Caring Nurse and Good Quality were sentenced to serve 108 and 51 months in prison, respectively.

A married Miami couple that owned a care clinic were sentenced in connection with an $8 million health care fraud scheme involving the now-defunct home health agency company that purportedly provided home health and physical therapy services to Medicare beneficiaries. They were sentenced to serve 87 months in prison and 57 months, respectively, for conspiracy to commit health care fraud. They billed, among other things, expensive physical therapy and home health care services that were not medically necessary and/or not provided. The couple paid kickbacks and bribes to patient recruiters who provided patients for the company, and to co-conspirators in doctors’ offices and clinics in exchange for home health and therapy prescriptions, medical certifications, and other documentation.

Using Phony Social Security Numbers to Obtain Benefits

Two individuals pled guilty in West Palm Beach to obtaining multiple social security numbers to obtain federal housing, social security, food, cash, and medical benefits from the U.S. Department of Housing and Urban Development, the Social Security Administration, the U.S. Department of Agriculture, and HHS, as well as in buying a number of real estate properties. The guilty pleas were for making false statements to the federal government.

Mental Health Services Fraud

A licensed mental health counselor at the defunct health provider Health Care Solutions Network Inc. pleaded guilty today in Fort Lauderdale, Fla., for his role in a $63 million health care fraud scheme. The mental health facility purportedly provided Partial Hospitalization Program (PHP) services were routinely fabricating patient medical records to support false and fraudulent billing to government sponsored health care benefit programs, including Medicare and Florida Medicaid.

False Statements to Obtain Controlled Substances

In South Dakota, a federal grand jury returned an indictment for False Statements Relating to Health Care Matters and Attempt to Obtain Controlled Substances by Fraud. The charges relate to presenting a falsified prescription for Hydrocodone, a Schedule III controlled substance, to the Indian Health Services Pharmacy

Hospitalist Fraud

The government has intervened in a qui tam lawsuit against the Hospitalist Co. Inc., and its North Hollywood (CA) subsidiary IPC, for submitting false claims to federal health care programs. IPC is one of the largest providers of hospitalist services in the United States, employing physicians and other health care providers who work in more than 1,300 facilities in 28 states. The lawsuit alleges that IPC physicians sought payment for higher and more expensive levels of medical service than were actually performed—a practice commonly referred to as “upcoding.” Specifically, the lawsuit alleges that IPC encouraged its physicians to bill at the highest levels regardless of the level of service provided, trained physicians to use higher level codes, and encouraged physicians with lower billing levels to “catch up” to their peers.

Doctor Sentenced For Health Care Fraud

A Youngstown, New York doctor, who previously pleaded guilty to obtaining controlled substances by fraud and health care fraud, was sentenced to six months of home detention and two years’ probation, and loss of his medical license. He had been employed as an emergency room physician where he devised a scheme with his girlfriend, who pretended to suffer from a medical condition known as Trigeminal Neuralgia. He then performed an apparent examination of her, fraudulently diagnosed her and issued a prescription to her for Dilauded®, a controlled substance.

Medical Supply Company

In San Antonio, a federal grand jury returned a 21 count indictment of DTS Medical Supply Company’s owner and two employees in connection with an estimated $3.5 million health care fraud scheme involving identity theft and eight counts of aiding and abetting false statements related to a health care matter. Medicare and Medicaid set a rate of compensation for each of these devices; the rate of compensation differed between devices and was to be based on the type of device that was prescribed for and delivered to the beneficiary. The defendants were charged with conspiring to submit numerous false and fraudulent benefit claims to Medicaid and Medicare in seeking compensation for powered wheelchairs, when less costly power scooters were delivered. The fraud involved paying a recruiter to recruit customers.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2013 Strategic Management Services, LLC. Published with permission.