Confined by Fraud

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Home health care agencies generally provide quality health care to patients who are confined to their residence. When unable to leave their home, a home health care provider sends in qualified staff to assist with any medical or personal needs. Today’s ”Fraud of the Day” tells about a home health care business manager in Illinois who used fraudulent billing practices to receive Medicare dollars. (She headed up a scam that provided home health care to patients that were not actually confined to their homes and billed Medicare as if they were.)

The woman’s scam involved directing her employees to bill Medicare for more complicated and higher priced services than were actually provided. (She claimed that the business provided these higher priced and more complicated services to home bound patients, when in reality, they were actually capable of leaving their homes and travelling to a medical facility for treatment.)

As always, fraudsters usually need a team to help carry out their fraudulent deeds. The business manager relied upon a physician to falsely certify that her patients required in-home nursing care. (The doctor alone caused more than $2.6 million in losses to Medicare.) Another co-conspirator – a nurse – operated two nursing agencies who provided staffing. (He was also responsible for billing Medicare for unnecessary services, which as you might guess were authorized by the woman who managed the home health care agency.)

The 47-year-old business manager was ultimately convicted by jury on 21 counts of health care fraud and three counts of making false statements. She was sentenced to six years in prison and ordered to pay $15.6 million in restitution. Her two conspirators pleaded guilty to their fraudulent crimes.

Today’s article states that prosecutors had audio recording evidence that revealed that the business manager had encouraged doctors to ”paint the picture” that her patients were confined to their homes. Other email evidence showed that she preferred co-conspirators who would sign off on orders without actually reading them. (Ironically, while she claimed her patients were confined to their homes, it is actually she that will be confined to her prison cell for the next six years.)

Source: Today’s ”Fraud of the Day” is based on an article entitled, ”Schaumburg Home Health Care Manager Sentenced to 6 Years for Medicare Fraud, $15.6 M Restitution,” posted on on August 2, 2016.

A Streamwood woman who headed a Schaumburg-based home healthcare business was sentenced to six years in prison and ordered to pay $15.6 million in restitution Tuesday, July 26 in a federal courtroom in Chicago by U.S. District Judge Charles Kocoras.

In April, Diana Jocelyn Gumila, 47, of Streamwood, manager of Suburban Home Physicians, doing business as Doctor at Home, was convicted by a jury of 21 counts of health care fraud and three counts of making false statements in a healthcare matter for inflating costs incurred by Medicare by directing employees to bill treatment at the most complicated levels, increasing costs, and performing in-home treatment for patients capable of leaving their homes and traveling to a medical facility for treatment, prosecutors said.

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Larry Benson, Senior Director of Strategic Alliances, LexisNexis Risk Solutions - Government

Larry Benson is responsible for developing strategic partnerships and solutions for the government vertical. His expertise focuses on how government programs are defrauded by criminal groups, and the approaches necessary to prevent them from succeeding.

Mr. Benson has 30 years of experience in sales and business development. Before joining LexisNexis® Risk Solutions, he spent 12 years founding and managing two software technology startups. During the 1990s he spent 10 years as a Regional Director helping to grow a New England-based technology company from 300 employees to 7,000. He started his career with Martin Marietta Aerospace working on laser guided weapons and day/night vision systems.

A sought-after speaker and accomplished writer, Mr. Benson is the principal author of “Fraud of the Day,” a website dedicated to educating government officials about how criminals are defrauding government programs. He has co-authored WTF? Where’s the Fraud? How to Unmask and Stop Identity Fraud’s Drain on Our Government, and Data Personified, How Fraud is Changing the Meaning of Identity.

Benson holds a Bachelor of Science in Physics from Albright College, and earned two graduate degrees – a Master of Business Administration from Florida Institute of Technology, and a Master of Science in Engineering from Lehigh University.