On November 30, 2021, a Chicago woman was sentenced to 56 months in prison and ordered to pay $6.3 million in restitution for her participation in a conspiracy to commit healthcare and wire fraud.
Per the court documents in this case and the evidence that was presented at trial, the Chicago woman was employed at a home care company. From 2011 to 2017, the home care company fraudulently billed Medicare for at least $6.3 million. During the trial, the government proved that around 90% of the patients were not homebound and did not qualify for the services that the home care company billed to Medicare. Additionally, many patients received cash bribes to receive home health visits, some of which were performed in the visiting nurse’s car.
The Chicago woman facilitated the conspiracy by falsifying patient visit records which were used to support claims billed to Medicare. She was convicted by a federal jury on February 14, 2020. One co-owner of the home care company was sentenced on October 21, 2021, to 84 months confinement and three years supervised released. The second co-owner of the home health company was sentenced on November 5, 2021, to 60 months confinement and three years’ supervised release. Another participant in the conspiracy pled guilty, cooperated with the government throughout the investigation, and was sentenced to a term of three years’ probation.
Issue:
The Centers for Medicare & Medicaid Services (CMS) requires that organizations receiving government funds have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care. Routine audits should be conducted of documentation of services provided and related billing, and the results of the audits should be reported to the compliance and ethics committee and to the governing body. Any discrepancies discovered by the auditing activity or any suspicions of antikickback violations should be investigated and rectified immediately.
Discussion Points:
- Review your policies and procedures for preventing false claims and kickbacks, and ensure that they are current. Review the policies at least annually and update when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures for prevention, detection, and reporting of false claims or kickbacks. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure that all staff are aware of compliance and ethics requirements and understand their responsibility to report any suspicions of compliance and ethics violations to their supervisor, the compliance officer, or via the anonymous hotline.
