Mobile Health Care Provider Fraud: How Physicians, Managers & Owners Become Suspects
Medicare believes it is paying billions of dollars every year to doctors who claim they’re making house calls but actually aren’t.
So what does that mean for you if you are a physician (or if you’re a home health nurse, a mobile radiology or diagnostics business owner, a home-delivery pharmacist, or so on) who really does make house calls for patients covered by Medicare, Medicaid, or TRICARE?
Frankly, it means you’re working in a small-but-growing sector of the health care market one the government has said in no uncertain terms that it is deeply suspicious of. And so the bills you send to the CMS are more likely to trigger audits, investigations, or reviews.
Mobile health care provider fraud is a real concern for anyone providing home health services in the United States. The consequences are titanic an investigation that can bring your business to a grinding halt, the possibility of losing your license or your DEA registration privileges, prison time, and potentially millions of dollars in restitution and fines.
In today’s article, we consider a case out of Chicago in which a nurse who also managed her own home health care company was arrested for Medicare fraud. We will also review what this case reveals about how physicians, nurses, business managers, medical clinic owners, and other white-collar professionals end up as criminal suspects in federal court.
Case in Point: A Home Health Nurse-Manager in Chicago Arrested for Medicare Fraud
Diana Jocelyn Gumila is a registered nurse (RN) who was also operating a suburban health care company, Doctor at Home, when she was arrested by federal agents on charges of extensive Medicare fraud. Gumila was 45 at the time and had been a licensed nurse in the state of Illinois since 1991.
The Doctor at Home’s business model involved sending physicians (MDs) and physician’s assistants (PAs) to patient’s homes for personalized residential care. A medical assistant would accompany the doctors on their visits and provide transportation. Many of Doctor at Home’s patients were reportedly referred to them by home health agencies.
The federal government alleges:
- These home health agencies worked with Doctor at Home so that a physician would order the agencies to provide home nursing services for patients. But many of the patients did not actually need those services.
- Doctor at Home schemed to falsely certify patients as being confined to their homes and requiring home health services in order to qualify for Medicare coverage.
- From 2013 to 2014, more than 300 home health agencies submitted Medicare claims that had been ordered by just four Doctor at Home physicians. In total, these four physicians had allegedly ordered home health services for some 4,000 patients resulting in more than $20 million in Medicare payments to the home health agencies.
- Most of the Doctor at Home physician visits purported to be complicated in nature with an average payment of about $120 per visit. But in reality, they were usually short and routine in nature.
- Nurses visited the home health care patients weekly or monthly, whether they needed it or not. Doctor at Home assisted the home health agencies in creating these false bills (sometimes totaling more than $1,000 per patient per month for basic nursing check-ups).
- Doctor At Home allegedly maintained a practice of double-billing the same visit as both a “patient visit” and a “wellness visit.”
- Gumila’s business allegedly used employees in the Philippines to prepare oversight claims, but then passed them off as having come from the visiting physicians.
- Gumila also allegedly overruled at least one physician as to the medical necessity of home health care services.
To gather evidence, federal agents from the FBI, HHS, OIG, and other law enforcement agencies worked together and:
- executed search warrants (not only at the Doctor at Home offices but also at a mobile imaging company that did business with them).
- executed a warrant to seize the proceeds of the alleged fraud from Doctor at Home’s business banking account.
- obtained statements from seven former Doctor at Home employees.
- received information from a then-current employee of Doctor at Home, a PA, who contacted law enforcement as an informant six months prior to the arrest.
- obtained audio surveillance from a former Doctor at the Home physician, who had recorded a meeting with Gumila.
- obtained emails, patient files, claims data, and other documents.
- interviewed Doctor at Home patients, as well as those patients’ primary care doctors, who provided statements that contradicted Doctor at Home’s billing records.
Ultimately, investigators say they found sufficient evidence of:
- Upcoding
- Over-scheduled patient visits
- Double-billed patient visits
- Billing for medically unnecessary tests (including echocardiograms, ultrasounds, and eye-movement tests)
- False claims
- Certifications of home health care services for patients who were not confined to the home
In addition to the mandatory fine of $250,000 and $15.6 million in restitution to Medicare, Gumila was sentenced to 72 months (six years) in federal prison followed by 24 months (two years) of supervised release well below the ten-year maximum sentence, but a devastating and life-altering sentence nonetheless.
The U.S. Seventh Circuit Court of Appeals affirmed Gumila’s sentence on appeal.
What the Chicago Case Tells Us about Mobile Health Care Provider Fraud
What does the Gumila case tell us about how physicians, managers, nurses, and medical executives become the targets of federal investigations? A few facts stand out:
- Gumila was operating out of Chicago one of the nine U.S. cities with a Medicare Fraud Strike Force office that are assigned to the metros with the largest numbers of federal health care benefit recipients. While these offices conduct investigations nationwide, much of their work is focused on the metro areas they call home. Sure enough, it was the Chicago Strike Force office that oversaw the Doctors at Home investigation.
- Doctors at Home first came on the Strike Force’s radar when one of its current employees contacted agents as an informant. Patients and employees are among the most common government informants of mobile health care provider fraud.
- During the recorded conversation with the physician, Gumila was discussing several patients who the doctor felt did not qualify for certain services. Gumila reportedly told the doctor she was an “artist” who should “paint the picture” of each patient in a way that Medicare would accept. While the surrounding context of that conversation isn’t clear, others in the health care industry should take note. Audio and video surveillance are common in federal health care fraud investigations, and it’s all too easy for careless or loosely worded statements to be used against you.
- Gumila had been under investigation for at least six months. Her indictment remained under seal until the date of her arrest. Care providers often do not know they are being investigated (or even that they are the subject of a grand jury proceeding) until charges are filed.
Accused of Mobile Health Care Provider Fraud? Please Call Our Defense Attorneys
The Criminal Defense Firm team of health care fraud and white collar defense lawyers have successfully defended numerous medical care providers and business owners including those accused of fraud in the home health services field.
We offer years of insight into federal health care fraud investigations. Put our experience on your side. Call 866-603-4540 for a free consultation today.
Mobile Home Health Fraud Defense for business owners and care providers in Dallas and across the country (primary office in Dallas, TX).
Brian Kuester offers his extensive experience to counsel companies and individuals under civil or criminal government investigation. When resolution requires litigation, clients choose Mr. Kuester’s proven court and litigation experience.