By Sonal Patel BA, CPMA, CPC, CMC, ICDCM SP Collaborative |
Monthly Spotlight on Fraud, Waste, and Abuse - August 2023


Monthly Spotlight on Fraud, Waste, and Abuse - August 2023

Date Posted: Monday, August 21, 2023


The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services. 

A Former Louisiana Hospice Care Owner Convicted of Defrauding Medicare

A federal jury returned a guilty verdict against a former hospice care owner for one count of conspiracy to commit healthcare fraud and three counts of healthcare fraud following a trial that lasted almost one month.

She was the owner of a hospice care corporation that was purported to provide hospice services to patients who were terminally ill.

Through evidence presented at trial, jurors learned that from approximately 2009 through 2017, over 24 patients were placed on hospice by this hospice care corporation without meeting the criteria required by Medicare. 

During the time that the patients were on hospice and under the care and supervision of this hospice entity, none of them had been diagnosed with a terminal illness. 
In fact, many of the patients themselves, who are still alive and thriving many years later, as well as family members of other patients, testified that they never knew that they had been placed on hospice. 

The testimony revealed that, while on hospice care, many of the patients were living normal lives, and although most of them did have medical conditions, none had been diagnosed as being terminally ill. 

The fraudulent claims submitted to Medicare and reimbursed to the hospice corporation resulted in a loss of approximately $1.5 million.

As the owner of the hospice care corporation, this woman faces a sentence of up to 20 years in prison on the conspiracy to commit healthcare fraud charge, up to 10 years in prison on the healthcare fraud charges, 3 years of supervised release, and a fine of up to $250,000.

Read the specifics of this case at www.justice.gov

A South Florida Man Sentenced with Prison Time After Buying and Selling 2.6 Million Medicare Beneficiary Identification Numbers

A man was sentenced in federal court to 41 months in prison following his earlier guilty plea to buying and selling more than 2.6 million Medicare beneficiary identification numbers, along with other personal identifiers.

In one of the first prosecutions brought under The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), this man was sentenced to 41 months imprisonment following his guilty plea to one count of conspiracy to violate MACRA by buying and selling beneficiary identification numbers. 

Among other things, MACRA makes it illegal to buy, sell, or distribute without lawful authority Medicare or Medicaid beneficiary numbers (Title 42, United States Code, Section 1320a-7b[b][4]).

As part of his plea, he admitted that he and his co-conspirators used "data mining" and "social engineering techniques" to collect Medicare beneficiary information, which he then advertised and sold online. 

The trafficked information included beneficiary names, addresses, dates of birth, social security numbers, and Medicare beneficiary identification numbers. 

According to the indictment, some of the illicit transactions involved foreign actors, including sellers in the Philippines and buyers in Egypt. 

Read more about this case at www.justice.gov

An Adult and Pediatrics Healthcare Practice Has Agreed to Pay $3 Million to Settle FCA Allegations

A Virginia adult and pediatrics practice has agreed to pay $3,000,000 to resolve allegations that it violated the False Claims Act by engaging in fraudulent billing activities between January 2017 and May 2021 with regards to pediatric in-home health, personal care, and related services.

From 2017 and continuing through May 2021, this pediatrics healthcare practice allegedly billed its state Medicaid for reimbursements for in-home healthcare services for pediatric patients who were actually hospitalized at the time the in-home services were billed. 

They allegedly routinely billed the state Medicaid for home health services that were not actually provided.

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act against the adult and pediatrics practice.

The state's Attorney General said, "Those who take advantage of Virginians during some of their most vulnerable times must be held accountable. Thanks to the excellent work done by my office and our federal partners, this organization will have to answer for its illegitimate billing methods that exploited hospitalized pediatric patients."

The claims resolved by the settlement are allegations only and there has been no determination of liability.

Read additional details of this case at www.justice.gov

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is the CEO and Principal Strategist for SP Collaborative, serving as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical codes, auditors, and compliance professionals to elevate coding compliance education for the business of medicine.

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