Must a nurse investigate suspicions that certifications of medical necessity may be for unnecessary services in order to minimize the risk of violating the False Claims Act? [F602 Free from Misappropriation/Exploitation, F609 Reporting of Alleged Violations, F710 Resident’s Care Supervised by a Physician]
Compliance Perspective – Medicare Fraud Scheme
Policies/Procedures: The Compliance and Ethics Officer, the DON, and the Administrator will review policies and procedures that address physician certifications for medical necessity.
Training: Staff must receive periodic training on the process and requirements for physician completion of Medicare necessity certifications.
Audit: An audit of physician certifications will be conducted periodically to ensure medical necessity certifications and healthcare provider services information coincides and agrees with patients’ needs.
Two Texas doctors and three nurses were sentenced in an $11.3 million Medicare fraud sche
me involving false and fraudulent claims for home health services. The doctors (Kelly Robinett and Angel Claudio) will serve 42 months and six months respectively. Patience Okorojo was given 120 months, Joy Ogwuegbu and Kingsley Nwanguma both received sentences of 42 months. Okorojo was a part owner of Timely Home Health Services Inc. (Timely), Ogwuegbu was Timely’s Director of Nursing and Nwanguma was an LVN at Timely. Two others who pleaded guilty in the case are awaiting sentencing.
From 2007 through 2015, the five sentenced were engaged in a scheme to defraud Medicare by submitting and causing to be submitted false claims from a home health agency and a physician house-call company. Individuals never seen by a doctor were certified as Medicare beneficiaries eligible for medical home health services that were medically unnecessary and often not provided. The nurses falsified nursing assessments and nursing notes to make it appear the patients were certified Medicare beneficiaries and were receiving skilled nursing services.
Along with the $11.3 million in fraudulent claims related to Timely, another 1.6 million in fraudulent billing was associated with the physician’s house-call company for medically unnecessary home health certifications, services, and physician’s home visits.
