Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Risk Management News

Home Health Owners Face Charges for Medicare Fraud, Upcoding

Recent Medicaid and Medicare fraud cases involved false billing, upcoding, and bribery, resulting in hefty fines and prison time for physicians involved.

Medicare fraud and healthcare fraud

Source: Thinkstock

By Jacqueline LaPointe

- The federal government filed a lawsuit against the two owners of Gateway Health Systems in Chicago for their involvement in a Medicare fraud scheme that cost the federal healthcare program millions, the Department of Justice recently announced.

The suit alleged that husband-and-wife owners Ajibola Ayeni and Joy H. Turner-Ayeni defrauded Medicare by billing for medically unnecessary or nonexistent home health services.

Persecutors also stated that Ajibola Ayeni’s other healthcare organization, Docs at the Door PC, improperly certified patients as homebound individuals even though the patients did not require home health services. The company also reportedly upcoded home visits performed by physicians to the second highest billing level to maximize Medicare reimbursement.

A time and distance analysis of the Medicare bills submitted by Docs at the Door uncovered that a visiting physician would have needed to perform services for a full 24 hours a day in order to deliver the volume of services claimed on some dates, reported The Chicago Tribune.

As part of the Medicare fraud case, the federal government is also intervening in a sealed 2013 lawsuit filed by a whistleblower.

READ MORE: How Providers Can Detect, Prevent Healthcare Fraud and Abuse

The two defendants in the lawsuit could face civil penalties ranging from $5,500 to $11,000 for each fraudulent claim submitted. The court could also recover up to three times the damages on top of the penalties.

Additionally, Ayeni is involved in separate criminal charges associated with his alleged Medicare fraud scheme at Docs at the Door. The federal government accused Ayeni of committing healthcare fraud from 2011 to 2015 and covering up the crime.

Federal officials contended that Docs at the Door and Gateway health Systems submitted claims and received Medicare reimbursement for services reportedly delivered to beneficiaries. Ayenis allegedly directed his staff to create false documentation to show that the services were delivered even though beneficiaries never received care or the care was medically unnecessary.

The lawsuit also alleged that Ayenis tried to conceal property assets from the government. He “either intentionally transferred the properties to avoid paying a judgment to the United States for their fraud, or at a minimum, knew that they had incurred debts that they would not be able to pay,” the lawsuit stated.

Ayenis pleaded not guilty to the criminal charges. The federal court in Chicago has yet to set a trial date.

Three more doctors receive jail time for test referral bribery in NY, NJ

READ MORE: DOJ Charges 3 Individuals in $1B Medicare Fraud Scheme

A federal judge recently sentenced three New York-based providers to two years or more in prison for engaging in a healthcare fraud scheme involving test referrals and over 30 other providers.

Brothers George Roussis and Nicholas Roussis, as well as Ricky J. Sayegh, pleaded guilty earlier this year to separate claims that they each accepted bribes in exchange for test referrals to Biodiagnostic Laboratory Services LLC (BLS), of Parsippany, New Jersey.

George Roussis, a pediatrician, and Nicholas Roussis, an OB-GYN, owned practices in Staten Island. The brothers accepted a total of $175,000 in cash from BLS employees and associates between October 2010 and April 2013. BLS also improperly paid for personal expenses incurred by the providers.

George Roussis and Nicholas Roussis, then, referred blood specimens of their patients to BLS. The referrals produced over $1.45 million and $250,000 in revenue for the lab, respectively.

The providers were sentenced to 37 and 24 months in prison, respectively. They must also pay $7,500 and $5,000 in fines.

READ MORE: Using Big Data in the Hunt for Healthcare Fraud, Waste, and Abuse

Sayegh, an internal medicine provider in Yonkers, New York, admitted to taking about $400,000 in cash bribes from the laboratory organization from February 2010 to April 2013. His test referrals generated more than $1.4 million in revenue for BLS.

He faces 30 months in prison and a $10,000 fine for his involvement in the bribery scheme.

In addition to these three providers, the healthcare bribery investigation has yielded 50 convictions, with 36 involving physicians. BLS admitted that the scheme resulted in over $100 million in payments to the laboratory organization from Medicare and private payers.

The federal government recovered about $13 million through forfeiture so far and BLS pleaded guilty and will forfeit all assets. The company is no longer operating.

Two health clinic operators admit to healthcare fraud scheme

Shawn Thorpe and Ruben McLain recently pleaded guilty to conspiracy to commit healthcare fraud after the federal government accused the individuals of allowing McLain to practice medicine and bill for services despite being previously excluded from federal healthcare programs.

The defendants, who established and managed Coastal Bay in Florida, admitted that they knew McLain was prohibited from billing federal healthcare programs like Medicare and Medicaid for healthcare services. The federal government had revoked McLain’s right to participate in the programs after a 2011 federal conviction for healthcare fraud, the DoJ stated.

However, Thorpe failed to alert the Medicaid program that he partnered with the excluded provider.

He also allowed McLain to continue to practice and bill for services. To cover up the violation, Thorpe and McLain admitted to billing for those services under an alias. Under the alias, McLain took on employment responsibilities, saw patients, and performed managerial duties.

McLain also had access to a Coastal Bay credit card, which he admitted to using for personal purchases in his home state of North Carolina. As a result, he and his immediate family received over $10,000 in direct payment withdrawals from the healthcare organization’s business account.

The judge ordered the maximum penalty of five years in prison for both of the Coastal Bay operators. They also face a fine up to $250,000.

Hospital operator in NY pays $4 million to settle healthcare fraud case

Accusations that New York-based MediSys Health Network Inc. violated the False Claims Act and Stark Law prompted the operator of two hospitals to pay $4 million to settle the allegations, the Department of Justice reported.

The hospital operator agreed to the settlement to resolve claims that the company submitted false Medicare claims for healthcare services delivered to patients who were referred by providers with whom the company had improper financial relationships.

The improper financial relationships included payment and office lease arrangements that violated the Stark Law. The law limits how hospitals can engage with referring providers, particularly in terms of compensation.

A whistleblower alerted the federal government of the healthcare fraud scheme.

“When hospital operators provide financial incentives to doctors for patient referrals, individuals rightfully wonder whose best interests are being served,” stated Scott J. Lampert, Special Agent in Charge at the HHS OIG. “We will continue to investigate such entities who fraudulently bill government health programs.”


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