Healthcare Compliance Perspective – False Claims Settlement:
The Compliance Officer will review the facility’s policies and procedures with the Compliance Committee to 
ensure that the facility has a “no prohibited claims submission policy” in place. Specifically, these procedures should include performing employee background and exclusion checks and providing adequate documentation and verification of services provided. Nursing staff will be educated regarding the importance of all documentation, HR personnel and billing staff will be educated regarding performance of employee background and exclusion checks and claims submission. Regular audits of the residents’ MDS, Charts and employee background and exclusion checks will be developed and implemented to discover errors or omissions that might result in potential submission of a false or prohibited claim.
A Virginia provider of in-home healthcare services has agreed to settle allegations that it submitted false claims to the Virginia Medicaid Program which would violate the False Claims Act. The allegations brought by the U.S. Attorney’s Office and the Virginia Attorney General’s office involved covered nearly three years from January 2011 through September 2013. Under the terms of the settlement, the provider will pay a total of $3,345,065.35 to the United States and Virginia.
The allegations included these four types of false claims: 1) Employing and submitting claims for uncertified “personal care aides” who were ineligible to provide services; 2) Falsifying documents and statements in order to qualify ineligible beneficiaries for services; 3) Making false statements in prior authorization requests in order to obtain approval and reimbursement for non-reimbursable “respite services”; 4) Engaging in “phantom billing” by billing for services that were not performed; and 5) Hiring family members of Medicaid beneficiaries as “personal care aides” and submitting ineligible claims for compensation for care provided by those family members.
The administrative director who is also the registered nursing supervisor in one of the company’s offices is named as a defendant. In the statement of facts about the settlement, the woman admitted to “knowingly and willingly executing a scheme to defraud the Virginia Medical Assistant Program.”
