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Last Updated on: 3rd November 2023, 07:11 pm
Home Healthcare Fraud: Who is Prosecuted?
Home healthcare fraud is a big problem these days. With more people needing home healthcare services, there are also more opportunities for fraud. But who exactly gets prosecuted for home healthcare fraud? Let’s take a look…
First off, it’s usually the home healthcare agencies themselves that get prosecuted. If an agency is billing Medicare or Medicaid for services that weren’t provided, weren’t medically necessary, or were provided by unqualified personnel, that’s fraud. Some common types of home healthcare fraud include:
- Billing for services not provided
- Billing for more expensive services than were provided
- Billing for services provided by unlicensed or unqualified personnel
- Billing for medically unnecessary services
- Falsifying patient records to show a need for services
When these agencies commit fraud, the owners and operators of the agency can be prosecuted. There are many cases of home health agency owners going to jail for healthcare fraud. Here’s a few examples:
In Miami, the owner of a home healthcare agency was sentenced to over 6 years in prison for billing Medicare for physical therapy and other services that were never provided. She also paid kickbacks to patient recruiters and doctors for fake prescriptions and referrals.
The owner of a home healthcare agency in Texas was sentenced to over 8 years in prison for billing Medicare and Medicaid for services not provided. He used the money to buy luxury cars, expensive homes, and vacations.
In Detroit, the owner of a home health agency was sentenced to over 4 years in prison for billing Medicare for physical and occupational therapy services that patients didn’t need.
As you can see, the owners and operators who orchestrate these fraud schemes often end up serving years in federal prison. But they’re not the only ones who can be prosecuted…
Employees Can Also be Prosecuted
Employees of home health agencies can also be prosecuted if they are involved in or aware of fraudulent billing. For example, nurses, physical therapists, office managers, and billers could all potentially face charges.
If agency employees falsify records, forge patient signatures, alter diagnoses, upcode services, or engage in kickback schemes, they are committing fraud. Some employees are coerced into fraud by owners and bosses. But others go along with it willingly. Either way, they can still be prosecuted.
For instance, in Louisiana, two nurses who worked for a home health agency were convicted of fraud for billing for care that they did not provide. They falsified records to show they provided services when they did not. Each nurse was sentenced to several months in prison.
In another case, the office manager of a home healthcare agency was sentenced to 2 years in prison for her role in a Medicare fraud scheme. She altered patient records and diagnoses to make them appear eligible for services.
So while owners are often the masterminds, employees can absolutely be prosecuted too if they are involved in carrying out the fraud.
Referring Doctors and Recruiters Also Prosecuted
It’s not just agency owners and employees who get prosecuted. Doctors and patient recruiters who receive kickbacks for referrals can face prosecution too.
For example, in Detroit a physician was sentenced to over 3 years in prison for referring patients to home health agencies in exchange for kickbacks.
In Houston, a marketer was sentenced to 15 months in prison for soliciting and receiving kickbacks in exchange for referring patients to home health agencies.
And in Florida, a patient recruiter was sentenced to almost 6 years in prison for soliciting kickbacks in return for providing home health agencies with Medicare beneficiary information.
The bottom line is if you participate in kickback schemes to generate fraudulent business for home health agencies, you could very well end up serving hard time in federal prison.
What About Patients?
You may be wondering – do the patients who receive the unnecessary services ever get prosecuted? In most cases, no. The patients are viewed as victims who were exploited and subjected to services they didn’t need. However, in rare cases patients have been charged if they were knowing and active participants in the fraud scheme.
For instance, in Louisiana a Medicare beneficiary was sentenced to 6 months in prison for their role in a home health fraud scheme. Prosecutors said the patient accepted kickbacks in exchange for accepting home health services they knew were unnecessary.
So prosecution of patients is very rare, but can happen if prosecutors can prove the patient was an active participant in the fraud, not just an unknowing victim.
How are These Cases Discovered?
You may be wondering how all these home healthcare fraud schemes come to light. There’s a few main ways:
- Whistleblowers – These are people who come forward to report fraud occuring at an agency. Often they are employees who see what’s going on first hand. They can receive a portion of the money recovered under the False Claims Act.
- Medicare Audits – Medicare contractors conduct audits of home health agencies and refer suspicious cases for further investigation.
- Law Enforcement – The FBI, HHS-OIG, and other agencies proactively investigate home health fraud using data analysis to identify red flags.
Once fraud is suspected, agencies will be audited and evidence such as patient records, phone records, financial statements, etc. will be gathered. Interviews are conducted with employees and patients. The full scope of the scheme is uncovered leading to arrests and charges.
What are the Penalties?
The penalties for home healthcare fraud can be severe. Penalties may include:
- 5-10 years in federal prison
- Fines up to $250,000 for individuals and $500,000 for companies
- Restitution payments back to Medicare/Medicaid
- Exclusion from participating in federal healthcare programs
Much depends on the scope of the fraud – the amount billed, the number of years, the number of patients, etc. But prison time is common in major fraud cases. The government takes Medicare fraud very seriously.
How Can Fraud Be Avoided?
The best way for home health agencies to avoid fraud allegations is to establish a strong culture of compliance. This includes:
- Implementing policies to prevent and detect fraud
- Conducting regular audits and monitoring billing
- Training staff on compliance requirements
- Encouraging employees to report concerns without fear of retaliation
- Promptly investigating any allegations of wrongdoing
- Disciplining employees who violate compliance policies
Agencies should also be very careful about patient eligibility for home health services. Only patients who are truly homebound and in need of skilled services should be certified for care.
Avoiding fraud requires vigilance and commitment from owners, managers and staff. But it’s far better than the alternative – facing prosecution, jail time, fines, and exclusion from federal healthcare programs.
So in summary, home healthcare fraud prosecutions often target agency owners and operators, employees who falsify records or engage in kickbacks, and doctors or recruiters who accept kickbacks. But patients are generally viewed as victims. And the best way for agencies to avoid issues is to implement a strong compliance program. Following the rules and providing appropriate care is always the wisest course of action.
I hope this overview has helped explain who gets prosecuted for home healthcare fraud and why. Let me know if you have any other questions!
Owner of Miami home health agency sentenced
Owner of Texas home health agency sentenced
Owner of Detroit home health agency sentenced
Louisiana nurses convicted of fraud
Office manager of home health agency sentenced
Detroit physician sentenced for kickbacks
Houston marketer sentenced for kickbacks