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Record $400 Million Fraud Case in Dallas

Home health remains the most fraud prone program for Medicaid and ranks high in Medicare as well. More cases involving home health fraud are brought by State Medicaid Fraud Control Units than any other type of provider. Home health programs have been a high priority for Medicare and Medicaid, as they are designed to help keep beneficiaries ambulatory in their own homes by providing them with personal care services. Health plans and providers have increasingly been moving to manage patients with chronic conditions and keep them out of emergency rooms, hospitals, and nursing homes. Supporting such efforts has been expected to not only improve the quality of life for beneficiaries, but also serve as a cheaper alternative for taxpayers, compared to the expensive institutionalized care in skilled nursing facilities. As a result, home health is one of the fastest growing sectors of health care, and the fastest growing sources of fraud.

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Underscoring this vulnerability is the massive fraud case out of Dallas that approached $400 million in fraud. The case is notable for being what officials have called the nation’s largest home health care fraud involving a single doctor. The Department of Justice stated that the fraudsters recruited fake patients, including some of the city’s homeless, to submit bogus health care claims. Records show that recruiters were paid $50 to walk into a homeless shelter and promise free meals to get recruits. To sustain the massive amount of paperwork, the ringleader set up a full-time forgery operation in which people were hired to sign in his name. The result was more than 11,000 Medicare claims submitted under the doctor’s name for referral for home health – the most in the nation for home health services. By contrast, it is typical for physicians to refer fewer than 100 patients for home health services. Another recent example of home health fraud involved owners and operators of seven home health care agencies in Miami that were found guilty of a $20 million Medicare fraud scheme that involved paying illegal kickbacks to patient recruiters, bribing medical providers for home health referrals, and asking co-conspirators to open shell companies for money laundering.

On the Medicaid side of the equation, the Government Accountability Office (GAO) released a report stating that personal care services for Medicaid beneficiaries continue to be at a high risk for fraud. Rapid growth of long-term care spending under Medicaid for services provided in home and in community settings now exceeds $80 billion, and is expected to grow to $111 billion by the year 2026. Currently, it already exceeds spending on institutional long term care. Fraud is such a problem that CMS has targeted six states for special action and has blocked new enrollment in CMS programs in those areas.

Connect With a Health Care Compliance Expert

Strategic Management has decades of experience creating, evaluating and improving compliance processes. If you would like assistance with your current Medicare or Medicaid compliance program, contact us online or give us a call at (703) 683-9600 to speak to a compliance expert today.

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