Compliance Perspective – Healthcare Fraud:
The facility is not involved in claims that outside healthcare providers submit to Medicare and Medicaid for services provided to residents. However, the Compliance Officer could, along with appropriate staff, periodically schedule educational group meetings with the residents and family members via the Residents’ and Family Councils to answer questions they may have about the statements they receive from reimbursement programs like Medicare and Medicaid. This could provide an opportunity for those attending to learn how to report suspicious claims for things like services not provided while fostering good client relations.The Compliance Officer should ensure that an audit is performed periodically to verify that vendors providing services, equipment or supplies to the facility have not been excluded or sanctioned by the OIG.
A speech therapist, previously excluded in 2012 from Medicare and Medicaid for filing false claims with South Carolina’s Medicaid program, has been convicted by a federal jury of committing a $2 million healthcare fraud scheme. Her conviction included one count of Healthcare Fraud, one count of Aggravated Identity Theft and four counts of Making False Statements Relating to Healthcare matters.
During the trial, evidence was presented tha
t showed how the defendant disguised her ownership and control over two healthcare providing businesses that were submitting claims to Medicare and Medicaid. The services for which claims were submitted were for speech therapy services that either were provided by other speech therapists or were never provided at all. The speech therapists in whose names the defendant submitted fraudulent claims testified in the trial, Other evidence was presented that showed the defendant also submitted claims for services to beneficiaries who were deceased.
For the Healthcare Fraud conviction, the woman could be sentenced up to 10 years in prison and up to five years for the False Statement conviction. The sentencing for those two convictions will be in addition to a mandatory sentence of two years for Aggravated Identity Fraud conviction.
