Highlight on Florida: Prison for administrator involved in home health Medicare fraud conspiracy

Medicare was scammed of $2.5 million in false and fraudulent claims and another of the conspirators is heading to prison. A home health administrator was sentenced to 126 months in prison for his role in the scheme after a two-week jury trial convicted him in December 2016 of one count of conspiracy to commit health care fraud and wire fraud and one count to defraud the U.S. and pay and receive health care bribes and kickbacks.

While the administrator was the manager of Mercy Home Care Inc. and a billing employee for D&D&D Home Health Care Inc. in Miami-Dade County, Florida, he and others submitted false claims through the companies to Medicare between October 2014 and June 2015, based on services that were (1) not medically necessary, (2) not provided, and (3) for patients brought to the companies through payment of illegal kickbacks to providers and recruiters. The claims the administrator submitted to Medicare were based on forged prescriptions and falsified medical documentation, backdated so services were supposedly provided in prior years, and for beneficiaries who were coached to say they needed services when they were not homebound. According to evidence from trial, he also destroyed evidence prior to his arrest. Medicare paid approximately $2.5 million for false and fraudulent claims submitted by Mercy and D&D&D.

Ten other co-conspirators previously pleaded guilty or were convicted by the Southern District of Florida, including the owner and president of Nerey Professional Services, Inc. That co-conspirator was convicted of one count of receiving kickbacks in connection with a federal health care program and one count of conspiracy to defraud the U.S. and pay health care kickbacks and sentenced to 60 months in prison on May 27, 2016. According to evidence from trial, the co-conspirator was involved in the conspiracy to accept kickbacks in return for referring Medicare beneficiaries to Mercy and D&D&D to serve as patients, even those who did not qualify for home health care services, between October 2014 and September 2015.

Fighting home health and ambulance fraud by putting providers on a map

CMS released public data sets and a mapping tool regarding the availability and use of Medicare services provided by ground ambulance suppliers and home health agencies. The data release is intended to improve care delivery through transparency and information sharing. CMS is using the data to identify areas where services are saturated and where there are high risks of fraud and abuse.

Data

On February 2, 2016, CMS announced a six-month extension of the temporary enrollment moratoria on new ground ambulance suppliers and home health agencies sub-units and branch locations in Medicare, Medicaid, and the Children’s Health Insurance Programs (CHIP) in seven geographic areas (see Some new providers still unable to enroll in high-risk fraud areas, Health Law Daily, February 1, 2016). Together with the data and mapping tool, CMS believes it can use the moratoria to fight fraud and safeguard the federal healthcare programs.

Fraud

Home health providers see the data release as a signal from CMS that it plans to step up its home health fraud fighting efforts. Along with the data release, CMS announced plans to use the data to pinpoint high-risk providers for increased site visits. CMS also plans to engage in monthly monitoring of home health enrollment data in order to identify and deactivate providers that do not meet Medicare requirements.

Data tools

The Moratoria Provider Services and Utilization Data Tool includes interactive maps and a dataset to identify geographic areas that might undergo consideration for a new moratorium on provider and supplier enrollments. The data includes the number of providers in a given geographic area and identifies the number of beneficiaries that use a specific health service in a particular region. The interactive maps allow for comparisons between these regions. The tool was developed from ground ambulance and home health agency paid claims data covering October 1, 2014 through September 30, 2015. The data will be updated quarterly.