This week, nine people were charged with healthcare fraud involving a company that provided home care to residents of Western Virginia. A recently unsealed November 2023 indictment revealed the extent of the scheme.
All nine individuals that were charged were owners or employees of Adult N Pediatric Healthcare Service, a Medicaid-enrolled home health agency providing nursing, personal, and respite care.[1] The company is based in Fairfax, but has a branch office in Lovingston.[2] The charges involve care provided in Bedford County, Lynchburg, Charlottesville and other Virginia locations.[3]
Under the scheme, defendants conspired to submit false claims to Medicaid for services that were not provided to patients.[4] This included falsifying records and documentation in support of the fraudulent claims submitted for reimbursement.[5]
The case remains under investigation by the Federal Bureau of Investigation and the Virginia Attorney General’s Medicaid Fraud Control Unit. The U.S. Attorney’s Office for the Western District of Virginia is responsible for prosecuting the case.
Home health care fraud is unfortunately and all-too-common occurrence. In 2015, Medicare reimbursed more than 11,000 home health care agencies approximately $18.4 billion for their services.[6] The Centers for Medicare & Medicaid Services (CMS) estimates $10 billion of those payments—more than half of the total reimbursement—were improper or fraudulent.[7]
Types of Home Health Fraud
Home health fraud varies in nature, but the majority of the fraud involves home health agencies billing for services that are not provided or billing for services that are not medically necessary. The U.S. Office of Inspector General points to the following as “red flags” suggestive of fraud:
- Beneficiaries who have no recent visits with their supervising physicians to certify the ordered care ordered is medically necessary;
- Services that are not provided after a hospital or nursing home stay;
- Diabetes or hypertension diagnoses, which typically do not justify home health care services; and
- Beneficiaries with multiple home health readmissions in a short period of time.[8]
Individuals who “blow the whistle” on such fraud are entitled to a portion of the proceeds the government recovers, which can be substantial. For example, a $375 million home health fraud scheme in Texas.[9] Another example, a New Orleans jury convicted a home health company owner in a $34 million fraud scheme.[10] Lastly, a Miami doctor was sentenced to prison for his role in a $37 million Medicare fraud scheme against home health agencies.[11]
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[1] Nine Indicted in Federal Health Care Fraud Probe. US. Justice Dept. – Press Release. Jan. 9, 2024. Available at https://www.justice.gov/usao-wdva/pr/nine-indicted-federal-health-care-fraud-probe.
[2] Hammack, Laurence. Home Health Company With Southwest Virginia Clients Charged With Fraud. The Roanoke Times (Jan. 9, 2024). Available at https://roanoke.com/news/local/crime-courts/home-health-company-with-southwest-virginia-clients-charged-with-fraud/article_4fa7af5c-af12-11ee-b1a2-d3ce18b774f3.html#tracking-source=home-top-story.
[3] Id.
[4] Fields, Odyssey. Roanoke Grand Jury Indicts Nine People in Federal Health Care Fraud Investigation. WFXR Fox Roanoke (Jan. 9, 2024). Available at https://www.wfxrtv.com/news/regional-news/virginia-news/roanoke-grand-jury-indicts-nine-people-in-federal-health-care-fraud-investigation/.
[5] Id.
[6] Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases. U.S. Dept. of Health and Human Servs., HHS OIG Data Brief (June 2016). Available at https://oig.hhs.gov/oei/reports/oei-05-16-00031.pdf.
[7] Id.
[8] Id.
[9] Dallas Doctor and Three Dallas-Area Home Health Agency Owners Convicted for Running Large-Scale, Sophisticated Health Care Fraud Scheme, U.S. Dept. Of Justice – Pres Release (April 13, 2016). Available at https://www.justice.gov/usao-ndtx/pr/dallas-doctor-and-three-dallas-area-home-health-agency-owners-convicted-running-large.
[10] New Orleans Jury Convicts Company Owner and Doctor for Roles in $34 Million Fraud Scheme, U.S. Dept. of Justice – Press Release (Mar. 18, 2016). Available at https://www.justice.gov/opa/pr/new-orleans-jury-convicts-company-owner-and-doctor-roles-34-million-fraud-scheme.
[11] Miami Doctor Sentenced to 24 Months in Prison for Role in $37 Million Medicare Fraud Scheme Involving Miami-Area Home Health Agencies, U.S. Dept. of Justice – Press Release (Mar. 25, 2011). Available at https://www.justice.gov/opa/pr/miami-doctor-sentenced-24-months-prison-role-37-million-medicare-fraud-scheme-involving-miami.