An Illinois nurse practitioner (NP) recently pleaded guilty to knowingly participating in a scheme to defraud Medicare by performing medically unnecessary visits in nursing homes located in two of the state’s counties.
The 41-year-old NP carried out the fraudulent scheme during the period from May 30 to June 26, 2017, by seeing nursing home residents multiple times, examined them for only a few minutes at a time, generated progress notes that she knew contained misrepresentations and materially false statements about the services she had performed, and falsely reported that her visits met the billing requirements for complex subsequent nursing home encounters, when they did not.
Part of the NP’s guilty plea required her to admit to knowingly causing 251 false claims to be submitted to Medicare during the charged timeframe. Medicare paid the NP’s employer over $23,000 for those visits. The NP received $27 for each of the false claims she caused to be submitted for a total of $6,777.
Sentencing is scheduled for December 10, 2020, and the NP faces a possible sentence of up to 10 years in prison and $250,000 fine.
Compliance Perspective
Allowing an outside healthcare provider to perform medically unnecessary visits to residents and to then knowingly submit false claims based on misrepresentations in progress notes and materially false statements for reimbursement from Medicare is a violation of the federal False Claims Act and may place a nursing home at risk of losing its ability to participate as a Medicare and Medicaid provider.
Discussion Points:
- Review policies and procedures regarding the use of outside healthcare providers, e.g., NPs, and performing background checks to ensure they have not been excluded from Medicare and Medicaid participation.
- Train staff to be aware of situations where an outside healthcare provider is visiting residents excessively yet spending a very small amount of time with each visit, and how to report suspected potential fraud to their supervisor or through the facility’s Hotline.
- Periodically audit to determine the frequency and length of visits with residents by outside healthcare providers to guard against healthcare fraud by flagging excessive and short visits.
FRAUD MODULE 7 – AUDITING, MONITORING, RESPONDING, INVESTIGATING, AND LITIGATING RESPONSIBILITIES
