Providing medical equipment that is of lower quality than the equipment actually billed to Medicare is fraud and results in the submission of a false claim
Compliance Perspective – Fraud and Identity Theft
Policies/Procedures:The Compliance and Ethics Officer with the Administrator will review the policies and procedures for vendor contracts and the required background investigation of databases for excluded individuals and companies, prior to the execution of a contract.
Training:The Compliance and Ethics Officer with the Business Office Manager will ensure that staff are trained in all aspects of the vendor contract process and the procedures to be completed in performing background investigations and checking federal and state Medicare and Medicaid exclusion lists.
Audit:The Compliance and Ethics Officer with the Business Office Manager should personally conduct periodic audits to determine if any vendors providing services to the facility have been excluded or sanctioned regarding Medicare and Medicaid.
A federal jury recently found the owner of Southern Respiratory LLC, Detra Wiley Pate, guilty of 33 counts of defrauding Medicare and 8 charges of aggravated identity theft during the period 2014 through 2016.
Evidence presented during the trial showed that Pate submitted thousands of false claims, fabricated patient files, and falsified prescriptions from doctors. Claims for items such as heavy-duty wheelchairs would be submitted for reimbursement while cheaper, standard wheelchairs were provided to the patients. The difference between what Medicare reimbursed and the cost of the much cheaper quality of equipment was pocketed by Pate. Evidence in court showed that the money Pate defrauded from Medicare was used to pay for, among other things, a 1.5 carat diamond ring, a Rolex watch, and other jewelry.
No date has been set for Pate’s sentencing, but she faces up to 10 years for each count of the indictment, plus an additional sentence of at least two years on the 8 counts of aggravated identity theft.
