Recent enforcement actions by the U.S. Department of Justice showcase federal efforts to put the kibosh on fraudulent claims filed with government programs for therapeutic services.
Episcopal Ministries to the Aging, Inc. (EMA), a Maryland-based owner of skilled nursing facilities, agreed to pay the government $1.3 million to settle allegations of filing false Medicare claims, the DOJ announced. Prosecutors said the billings were for "unreasonable or unnecessary rehabilitation therapy."
The complaint accused EMA of assorted billing high-jinks meant to maximize reimbursement. Instead of evaluating patients individually to see what services they needed, for instance, the provider reportedly placed patients in the highest therapeutic level unless they couldn't tolerate that much therapy, the announcement noted. Then the provider allegedly delivered the least amount of care necessary to bill at the top-paying level. Moreover, the provider reportedly rounded up claimed therapy minutes rather than billing for actual minutes of care provided.
"Patients in our nation's nursing homes should not be left to wonder whether the therapy they receive is based on their own clinical needs, or is instead tied to the financial targets of the companies providing their care," said U.S. Attorney for the District of Massachusetts Carmen Ortiz in the announcement. When a nursing home uses an external rehabilitation therapy vendor, "the facility remains responsible for ensuring that its patients are receiving, and Medicare is paying for, reasonable and necessary care," Ortiz said.
Meanwhile, North Carolinian Claude Arthur Verbal II was sent to prison after fraudulently collecting at least $1 million from Medicaid through his behavioral health company, Infinite Wellness Concepts.
In actions called "despicable and illegal" by the government, Verbal was responsible for changing diagnosis codes to bill at higher levels, inflating the number of clients in group therapy, billing for services not done, submitting false treatment notes under forged signatures, allowing unqualified staff to perform healthcare services and creating fraudulent clinical assessments.
All this helped Verbal "build a $700K+ bank account and go on a diamond-encrusted shopping spree with the ill-gotten money," said Special Agent in Charge Derrick L. Jackson of the U.S. Department of Health and Human Services, Office of Inspector General, in a DOJ announcement.