A federal jury convicted a licensed Illinois psychologist of defrauding Medicare over the course of several years by causing the submission of fraudulent claims for psychotherapy services he never provided.
According to court documents and evidence presented at trial, the psychologist caused the submission of fraudulent Medicare claims from July 2016 through June 2019 for psychotherapy services purportedly provided to nursing home residents in Chicago and surrounding areas. His scheme included fraudulently billing for in-person services on dates that he was traveling outside of the country and fraudulently billing for psychotherapy purportedly provided to residents who were deceased.
The psychologist was convicted of four counts of healthcare fraud. He is scheduled to be sentenced on April 18, 2023, and faces a maximum penalty of 10 years in prison on each count. A federal district court judge will determine any sentence after considering the US Sentencing Guidelines and other statutory factors.
The FBI and HHS-OIG investigated the case, which was brought as part of the Chicago Strike Force, supervised by the Criminal Division’s Fraud Section and the US Attorney’s Office for the Northern District of Illinois. Since March 2007, the Healthcare Fraud Strike Force Program, comprised of 15 strike forces operating in 24 federal districts, has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in healthcare fraud schemes.
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. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points:
- Review your policies and procedures for preventing and reporting false claims 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 staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A 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.
