No Recollection

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Today’s article explains a fraud case involving a lack of recollection. A Sugar Land, Texas nurse apparently did not recall the rules and regulations of running a legitimate home health agency and the government healthcare beneficiaries he victimized did not recall receiving any services from said home health agency. Fortunately, the justice system had no problem recalling the rules and regulations related to operating a home health agency that serves Medicaid and Medicare beneficiaries. Read on to find out about the nurse who got busted for committing healthcare fraud.

The Sugar Land nurse, who owned and operated a home services health agency in Richmond, Texas, allegedly paid marketers and group home owners for Medicare beneficiary information. He used the personal data to bill both Medicare and Medicaid for home health services they did not qualify for and/or did not receive. (That’s one of the oldest tricks in the healthcare fraud handbook.)

It is true that the agency owner had no recollection in terms of patients served. (That’s because he never served them.) He simply made up information to include on the patient assessment forms, causing them to appear more ill on paper than they actually were. (The nurse had his patients sign blank patient care forms which gave him carte blanche to bill as he pleased.) He also directed his employees to falsify home health certifications and forge the signatures of doctors to approve the orders. (This provided the backup he needed for billing Medicare at a higher rate.)

To keep the scheme running, the agency owner paid a co-conspirator kickbacks to drum up business for his company. Court records show that over five-and-a-half years, the registered nurse submitted fraudulent claims to Medicare and Medicaid, resulting in the electronic transfer of government funds totaling $3,534,972 into a bank account he controlled. (To throw the government off his trail, he transferred that money into other bank accounts, then disbursed payments to other co-conspirators and patient recruiters, paying up to $500 for a health certification and $250 for a recertification.)

However, there was just one small problem. Beneficiaries, who were all residents of Nacogdoches, Texas, did not recall being treated by the Houston physicians listed on their home health orders. (Again, that’s because the patients never received the services in the first place.) Investigators from the Department of Health and Human Services and the Texas Attorney General’s Medicaid Fraud Control Unit took it from there.

After a three-day trial, a federal jury convicted the Sugar Land, Texas nurse of healthcare fraud after deliberating for less than six hours. When sentenced, the former agency owner faces up to 10 years in federal prison for each count of healthcare fraud (60 years) and up to five years for conspiracy to violate the anti-kickback statute. His 59-year-old patient recruiter previously pleaded guilty to conspiracy to violate the anti-kickback statute and is awaiting sentencing for her role in the more than $3.5 million healthcare fraud scheme. (To the best of my recollection and based on precedents set, I predict these two will be serving some time behind bars very soon. Let’s hope they will work on improving their ethical memory so they will not repeat the same mistake twice.)

Today’s “Fraud of the Day” is based on a Department of Justice press release entitled, Sugar Land Nurse Convicted in $3.5 Million Healthcare Fraud Scheme,” released on May 17, 2018.

HOUSTON – A federal jury has convicted a 51-year old Sugar Land nurse of conspiracy to commit health care fraud, six counts of health care fraud and conspiracy to violate the anti-kickback statute, announced U.S. Attorney Ryan K. Patrick. The jury deliberated for less than six hours following a three-day trial before convicting John Dubor.

Dubor owned and operated Care Committers Health Services home health agency in Richmond. During the three-day trial, the jury heard evidence that Dubor paid marketers and group home owners for Medicare beneficiary information and subsequently billed Medicare and Medicaid for home health services for which the beneficiaries did not qualify and/or did not receive.

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Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.