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Posts tagged ‘Medicare Fraud’

Turning Point


My understanding of the events that shook my world last night is that they began before Hurricanes Katrina and Rita.   Although I am not certain of this, it seems that an investigation into Abide Home Health began prior to the storms but the evidence was washed out to sea.   I can’t say if that’s true or not but it adds a level of interest to the story knowing that the agency had a new chance to do things right and chose not to do so.

The case involved over 20 defendants, illicit sex, a dash of racism, the mother of a prominent football player (The Honey Badger), a large oil company and two Zulu Queens.  For those of you not from the South, Zulu is a Mardi Gras parade and they were Carnival Royalty. This is a big deal in New Orleans social circles.

To be sure, this case was juicy.

Imagine for a minute that you are one Lisa Crinel involved in a romantic relationship with your lawyer when a search warrant is executed relating to a fraud investigation involving your business.  Imagine if it was signed by a federal judge who was married to your lawyer.  Now imagine that you are the lawyer when Lisa Crinel files a lawsuit alleging that the lawyer ‘“never informed Ms. Crinel that it was a conflict of interest for him to represent her and her company while carrying on an extramarital affair with her….”   Yes, indeed.  How else could she have known?  I’m betting the judge was unaware of the affair when she signed the search warrant because it didn’t include a cavity search.

For some people, Medicare fraud isn’t enough.  The original press release from the US attorney’s office in Eastern Louisiana alleges that Lisa Crinel created false documentation to support claims for two employees and her daughter so that they could collect money from the funds provided by BP to compensate real victims of the Deepwater Horizon oil spill.  Classy.

Moving right along, Ms. Crinel had already lost 1M to the feds who seized her property even before she was indicted.  This was interpreted by Lisa Crinel as being racially motivated because they did not seize the property of another Medicare defendant accused of the same crime.    I believe there is a possibility that something, other than race motivated that decision.  Could there have been a previous overpayment?  How strong were her ties to the community?  I have to admit, a beach in a country without extradition might have appealed to me if I were in that position.   I sincerely hope that federal investigators did not simply seize her property and bank accounts with no good reason prior to the indictment because in spite of mountains of evidence, Ms. Crinel was innocent until proven guilty.

The Turning Point

In October of 2015, Lisa Crinel woke up with a newly calibrated moral compass.  In exchange for a lighter sentence of no more than 8 years and an agreement from the Assistant US Attorney that all felony charges be dropped against her daughter who served as CEO, she pleaded guilty.  She explained her decision, ‘because I am in fact guilty, and because I did not want to put the government through the unnecessary expense and trouble of proving this in court. I also pled guilty because I understand that accepting responsibility for the wrongs that I have done is the first step toward correcting them.”

Of course, she also agreed to provide the prosecutors with any truthful cooperation in any way she could.  According to Ms. Crinel, this was a genuine personal turning point for her, not just a legal one.  Yes.  That’s what she said.

The Sad Part

Last night, four doctors were convicted of multiple counts of Medicare fraud.  The longest possible sentence I saw was 170 years although the sentencing date has not been set. yet.  Are they guilty?  I think they are.  I still don’t know all of the details but the Feds don’t lose.   They knew this case was their’s for the winning when they took it on.  They turn away far more cases than they accept and the do not indict until they are certain they have a case.

Of the four, I know one mainly through his office staff.  I know that he was with his grandson who was receiving chemo when his office was raided.  I do not believe this was an accident because I’ve heard too many other stories about the feds arriving when the targets of their investigation were least available.  I have followed behind this doctor and another and read their clinic and hospital documentation for years.  The truth is that they are razor sharp physicians who are responsive to their patients and the nurses who call them for orders.

They are basically good men.

So, what happened? One doc received $3,500.00 a month from the agency – $1,000.00 more than would be allowed by law assuming he worked for the paycheck.  None of the doctors were poor and they all made more money than most people reading this blog.

My anger towards the owner of the agency is what I hang on to while these questions still linger.  Lisa Crinel owned Abide Home Health.  Her daughter was the CEO.  They wrote and signed checks that went to physicians.  They paid a physician’s wife an inflated salary so that her husband would refer patients.

Did the docs approach her asking for a Medical Director position?  I bet they were approached by Lisa Crinel.  And what they saw was a successful business woman in New Orleans – an economic nightmare since the storms in 2006.  They saw someone who had overcome the odds and lived well.  They signed orders because she or her agents asked.  Did they trust that the orders were legitimate?

Did they get a little greedy rationalizing that the dollar amount of money may be technically fraud but they deserved it?

These physicians could not have realized they were risking what may amount to life sentences for the relatively small amount of money they received.  But that doesn’t matter.  The standard isn’t what you know but rather what a reasonable person in the same position has the responsibility to know.

Lisa Crinel had the jewels and cash paid for by the proceeds of the fraud.  She was a New Orleans socialite; queen of Zulu.  She was a leader of the community and she lead dozens of her followers to the jailhouse.  While the physicians earned most of their money providing care to patients, she stole all her money by committing fraud.  And when she ran out of lawyers available for affairs and the BP scheme fell flat and nobody would believe that her African American heritage was the reason the feds were picking on her, she turned on the very people she recruited to participate in her fraud scheme.  I’m not sure I have any respect for her.

And New Orleans has lost two great physicians and two more that may or may not be great.  I’m not disagreeing with the verdict but I still find it sad.   The jury found them guilty and I trust the jury.  But they are guilty of fraud; not of being scumbags who systematically scheme to steal as much as they can from the government.   Sometimes good people break the law.

A Memorable Comment


Two years ago, I posted about Beverly Cooper who was convicted of multiple counts of fraud and was facing up to a ten-year sentence in Federal Prison.  See Press Release.   She admitted to signing visit notes when unlicensed personnel made the visits giving the impression that she made the visits; among other things – lots of other things.  Signing off on a visit that was made by someone without a license could have easily proved deadly to a patient.  Maybe Ms. Cooper is lucky that she didn’t kill someone.

Today, I received a message from someone, apparently a friend of Ms. Cooper’s pointing out that nowhere in the indictment (or my blog post) was Ms. Cooper’s 15-hour work days or dying relative noted.  The writer asked if I knew how wonderful Beverly Cooper was and pointed out that everybody makes mistakes.

Frankly, it would not surprise me if Ms. Cooper was a good hearted, likable woman.  Unlike less sophisticated crime, fraud on this scale is usually committed by people who are genuinely likable.

The writer of the message mentioned other people involved in the indictment.  She wanted to know why I didn’t mention them as well.  Frankly, they were not included in the press release.  Furthermore, Ms. Cooper was a Registered Nurse.   This blog is all about nursing and nurses and those who occupy our worlds.  That’s why Ms. Cooper made the blog post list.

I don’t know the person who wrote me the email and I never have met Ms. Cooper before.  I was nowhere near Detroit where all of this took place.  I cannot begin to speculate on what might have happened.  But, I can make reasonable assumptions based upon the criminal cases I have worked with and some former clients.

  1. Cooper was likely tired and emotionally fragile based upon what the writer said. Masterminds of fraud are incredibly smooth at exploiting the weaknesses of others.  She likely was not the mastermind.
  2. My bet is that Ms. Cooper was paid far more than an RN in a similar position. Should someone offer you twice as much as you are making now, be aware.  You are not worth that much.
  3. Cooper may have convinced herself or have been convinced that ‘everyone does it’. Wrongo.
  4. There may be somebody in the mix who could be legitimately diagnosed as a sociopath. Being without a conscience is mission critical to projecting the confidence required to persuade accomplices to achieve your purposes.
  5. I would bet the farm that at some point long before her arrest, Cooper figured out that she was committing fraud and had to make a decision. It could have been loyalty to her employer, a need for money, fear of extortion or just greed that convinced her to stay.  Sometimes, folks are too overwhelmed to think about a major life change.
  6. If this case was even remotely similar to other cases, the agency was investigated for years prior to an arrest. Beverly Cooper and her co-conspirators may have become complacent since there was so much time between the investigation and the arrest.

Let me reiterate that I do not know anything about these people.  They are not the usual fraudsters in Louisiana where we have enough home grown fraud that I don’t have to go looking in places like Detroit.  I have met many others who have faced a similar circumstance; enough to make assumptions.  I have enjoyed their company and worked hard for them and their lawyers and I took their money for my services.  But, when a clear pattern of fraud exists, there is nothing that I can do.  Criminal attorneys are brought to their knees trying to find a defense for their clients when there is none.   These are not thuggish criminals.  They are well dressed, well spoken professionals who say and do all the right things.

Your task if you are reading this is to know what a compliant agency looks like so you can find one to work with or create one to attract the kind of talent that you need to bring your agency to the next level.

The compliant agency:

  • Makes a lot of mistakes – it may seem like even more because they talk about mistakes, bring them out in the open and find ways to avoid repeat mistakes.
  • Has a lot of information scattered around the office about a code of conduct, employee hotlines and compliance committees.
  • Welcomes questions as a door for teaching.
  • Makes sure that employees have an anonymous way to report fraud.
  • Takes reports of fraud offered in good faith seriously.
  • Provides far more education in fraud than anyone wants.
  • Looks at processes and doesn’t blame employees for mistakes that involve multiple people and departments. There’s plenty of time to blame others if it happens again.  Fix it and move on.

Mistakes are costly to be sure but not nearly so much as hiding mistakes.  If you inadvertently make a mistake that affects billing and are fired after reporting it, smile on your way out of the door.  You don’t want to be there.  The agency has just sent a message to everyone else that they have a zero tolerance policy for mistakes and future mistakes will be hidden away.

Ms. Cooper may have been caught up in a storm she could not escape.  She may have discounted her actions as inconsequential or have been convinced she would never be caught.  She has lost her family, her marriage and her job according to the person who emailed me today.  She is completely without dignity.  On top of all of that, she is facing jail time.

I can’t help but feel compassion for her but more importantly, I am bound and determined to give all of you who take the time out of your day to read my blog the information you need to avoid a similar fate.  Unemployment is not half as bad as jail.

The 150M Settlement


It doesn’t make me feel good to know that Amedisys has had an exceptionally poor quarter and has tentatively entered into an agreement with the Department of Justice for a 150M settlement. I admit I am a little curious about the reference to The Stark Self-Referral Matter referenced in Amedisys’s press release but not overly disturbed. What disheartens me is that I am no longer surprised by the fact that when I searched the Internet for information, there were hundreds of results that all reported on the stock price.  Nobody stopped to wonder how a 150M dollar settlement would affect the care that Amedisys is supposed to be providing to patients.

Does this mean that I do not agree with the settlement? I don’t know all the details but I think that if the Federal government is going to get between Amedisys and that much cash, a legitimate question arises about their ability to care for patients and compete in an overcrowded market.

Amedisys is clear that in paying 150M to the government that they are not admitting any wrongdoing. I do not believe that they are willingly entering into this agreement because they couldn’t figure out what to do with extra cash. Not admitting wrongdoing is not the same as denying any wrongdoing. If they stayed out of the grey areas, I suspect they would be more than willing to pay a fraction of that to good defense lawyers.

While I don’t know the specifics of the settlement, I do know that it takes a lot of money to care for patients. I may find a bullet in my head in the morning but I strongly believe that if Amedisys is to pay 150M to the feds then Amedisys should no longer be afforded the privilege of billing Medicare. There is no shortage of stellar, high performing agencies who could pick up the slack and most of these smaller players would have never been given another chance by Medicare.

Alternatively, if they have been assessed as compliant and capable of caring for patients then the feds should lessen the penalty to an amount that does not interfere with patient care.

Just sayin……

A Gross Distortion of Truth


Implemented in 2011 as part of the ACA, the Face-to-Face requirement was mandated as a way to prevent Medicare fraud.  Well known cases of fraud involved agencies paying physicians who have never seen a patient to sign orders.  The best known case is that of Jacques Roy in Texas who defrauded the government of 450M by running an orders signing factory. There are more cases like this but these agencies are in the minority.  Although it is inconvenient at times, it should not be too difficult to satisfy this requirement to prevent additional fraud and abuse.

    1. The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.
    2. The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.
    3. It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.
    4. It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

I received a copy of a face-to-face document last week and posted it below.  This patient has Parkinson’s disease, congestive heart failure and chronic pain.

image

As many of you can guess, it was denied.  Nobody doubts that the patient was eligible for services or that the services provided were reasonable and necessary.  The physician saw the patient on the 26th as indicated in the documentation and also daily while he was hospitalized.  Physical therapy was indicated as the reason for services in a section of the document I could not clip without revealing personal health care information.

So why was payment denied for this patient who met eligibility requirements and received much needed covered services?  The physician did  not write a ‘narrative’ because the silly doctor thought it was self evident why someone with diagnoses of pain, Parkinson’s Disease, congestive heart failure who kept falling despite use of an assist device was confined to the home.

This particular document was appealed recently so it was easy to find but I have scores of them in my computer from numerous clients from all over.  And most will be denied.

Medicare states:

The face to face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

Nobody could possibly have more knowledge of the above patient’s condition than the physician who saw the patient daily in the hospital and then signed a face to face document.  Shame on that physician for failing to use verbs and pretty language to describe the patient better.  Perhaps he thought the document to which the face-to-face encounter was attached would be read.  Wrongo.  As with all statutory denials, the work is over when the claim is denied.  Why take your time to read an entire chart or even the care plan if the claim does not meet billing requirements.

Adding to this are the thousands of face to face encounters that meet all requirements and are denied regardless.  When this happens, an appeal is sent to the QIC (the next level of appeal) and often the QIC finds that the face to face encounter did satisfy all requirements but another reason for denial is found.  This tactic essentially robs the agency of one level of the appeals process.  

After working in post acute care for all these years, my faith lies in home health and hospice.  We have not lived up to our potential as a sub segment of the industry, but we are getting closer every day.  It will be a moot point when congress and other policy makers hear information painting a picture of our industry as blatantly fraudulent and unable to follow even the simplest regulation designed to prevent fraud.  That is my concern.  We will be somehow be left behind as new budgets are developed and our reputation is tarnished.

And to this day, I believe that if we did live up to our potential, congress would be lining up to ask how we wanted to be paid instead of  dismissing us as criminals in scrubs.  We will never live up to our potential as long as education, consulting, inservicing budgets are dedicated to teaching nurses how to review the face to face document to fund payroll.

Most importantly, I want copies of all face to face documents that have been denied if you don’t mind sharing.  You can sanitize them by removing personal health information or I can send you a HIPAA agreement so you can send them as is.

I am losing faith that our government, the one who wants to control 20 percent of our economy with the ACA is being truthful when they state that the purpose of the face-to-face encounter is to combat fraud.  Color me cynical but I see it being bastardized as a way to deny providers payment for covered services rendered to eligible providers. 

 

Who’s Beverly Cooper?


New Place of Residence for Beverly Cooper

New Place of Residence for Beverly Cooper

Why should you even care who Beverly Cooper is? A friend, Kelly, sent a link to a recent HEAT team arrests.  Because I have worked so much with fraud over the past couple of years, almost nothing surprises me anymore.  Here’s the exception.

Beverly Cooper admitted to Federal Authorities that as a registered nurse:

‘she and others conspired to defraud Medicare through home health care companies operating in the Detroit area, including Reliance Home Care LLC, First Choice Home Health Care Services Inc. and Accessible Home Care Inc.  According to court documents, Cooper fabricated nursing visit notes and other documents to give Medicare the impression that she had provided home health care services, when, in fact, home health care was not needed and/or was not being provided’.

Wow!  We are not talking about a rogue nurse.  This woman systematically with cooperation from her employers signed legal documentation for the sole intention of defrauding the government.  The total billed fraudulently was over 5M.

This is the stuff that makes headlines and sets examples of what happens to people who commit fraud.  It is dramatic and so far away removed from our daily practices that we just look at it in awe.

What we miss is that the worst part about this case isn’t the legal implications at all. It is the clinical documentation that is now part of a patient’s medical history.  It is the patients who were not seen.  It is those patients who did not meet eligibility requirements and were seen.

So, while it may not take a lawyer to determine that the behavior here was illegal, I wonder if the lawyers and judges understand the gravity of the compromised clinical care.  Do they fully understand the the harm that could come to a patient when a hospital or other provider relies upon fiction stated as fact in a clinical record?  Do they even understand how easy it would be for a patient to die because medications or allergies weren’t documented appropriately?

There’s one way to ensure that they do.  The judge presiding over the case, The Honorable Victoria Robertson, can be contacted at:

United States District Court
for the Eastern District of Michigan
Theodore Levin U.S. Courthouse
231 W. Lafayette Blvd., Room 123
Detroit, MI 48226

Chambers Telephone Number
(313) 234-5230

Let Judge Robertson know, if she does not already, that this case is about so much more than fraud.  If we, as nurses, do not speak up, who will?  Who better understands the ramifications of fraudulent documentation than a nurse who has tried to take care of a patient who is relying on poor (though not fraudulent) documentation of a prior caregiver?

I hope they allow Ms. Cooper a computer in the Federal Penitentiary so she can spend her money on the internet.  I hope the Amazon order is enough to offset any regrets she has about compromising patient care. Most importantly, she should take up a healthy lifestyle because there are many nurses who would not be comfortable taking care of her should she become ill.

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