Medicare can cover in-home health care services when patients are confined to their homes due to illness or injury. The goal is to provide medical care that is just as effective but more convenient and ideally less expensive than hospital care. Not so when fraud is involved. The Chicago Sun-Times tells the story of an area doctor who defrauded Medicare of more than $4 million, using his authority to help home health care companies charge for in-home services for patients who were not confined to their homes. (So now the doctor will be confined to prison for a couple of years.)
The story states that the corrupt Chicagoan was the part-owner of a company that provided physicians’ services to home health care patients. Like many doctors, he sometimes acquired new patients through referrals. However, in exchange for these referrals, this physician certified that his patients were confined to their homes, entitling them to specialized in-home treatments, when at least 20 percent of them were not. (Why bother with a house call when you can lie about it instead?) The home health agencies that initially referred the patients to this doctor billed Medicare for more than $20 million in services based on his certifications, so prosecutors charged that Medicare lost at least $4 million in the scheme.
Reportedly, during his plea agreement, the defrauding doctor stated that he feared he would lose referrals from the home health agencies unless he certified that patients sent to him required in-home treatment. (An excuse that did not earn him a get-out-of-jail-free card.) The 62-year-old physician pleaded guilty to health care fraud and was sentenced to two years in federal prison.
This case teaches us that the 80/20 rule does not apply to fraud. Even if a physician only lies about the condition of 20 percent his patients, it still counts as 100 percent fraud, and government agencies are on the lookout for it. The doctor’s case was investigated by the Medicare Fraud Strike Force, a collaborative effort between the U.S. Dept. of Health and Human Services and the FBI, with prosecutors from the Justice Department’s Fraud Section and the U.S. attorney’s office.
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