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Medicare Fraud in Illinois Highlights Importance of Law Enforcement

Recent news provides another example of the effort of medical providers, such as nursing homes, to defraud the government through healthcare fraud. The agencies are Adonis Inc. and BestMed-Care Services Ltd., headquartered in Dolton, Illinois. The operator of two nursing home agencies in Illinois was arrested and charged with healthcare fraud. The allegations specified that he stole over $5 million “for unnecessary home care services” for nearly four years. The charge carries a maximum penalty of 10 years behind bars and a fine of the greater of $250,000 or twice the amount of the fraud.

The charges stem from the agencies paying a marketing company to refer patients to them for ostensibly “free services” only to tell the patients they needed certain care from skilled nurses, and then billing Medicare for providing that unnecessary care. This also included filing falsified nursing assessments for these patients. This most recent case again puts the spotlight on the importance of Medicare and Medicaid Fraud Units. In this case, the Medicare Fraud Strike Force’s investigation led to this arrest. It also highlights the importance of our laws in combating Medicare and Medicaid fraud to protect the system and patients:

False Claims Act

The False Claims Act has been in place to hold people and entities accountable for defrauding the U.S. government. It is a particularly important law in the healthcare industry. Many medical providers, like hospitals, or doctors, accept insurance through federally-funded programs like Medicare and Medicaid. Unfortunately, some medical providers submit fake claims for reimbursement, which is fraud. These can be for treatments or procedures never performed, or may be for treatments or medications that they provided or prescribed but which were entirely unnecessary. The FCA is crucial in combating Medicare and Medicaid fraud.

Anti-Kickback Statute

The Anti-Kickback Statute also helps combat healthcare fraud by making it illegal for medical providers to accept kickbacks from pharmaceutical companies and other entities that sell them medications or equipment, all in exchange for using or prescribing those companies’ products to patients. It also covers medical providers’ paying for patient referrals, like the case discussed here. Recent updates to the law through the ACA clarified that such kickbacks can also amount to false claims when doctors submit reimbursement claims to Medicare and Medicaid, since those reimbursements are for treatments, medications or referrals made in exchange for kickbacks. This is meant to protect the integrity of the healthcare system, the waste and abuse of federal funds, and most importantly to protect patients from unnecessary treatments done for the purpose of defrauding the government for ill-gotten gains.

In addition to civil liability that can result in recovery and substantial fines and penalties, the Department of Justice will also prosecute offenders under the criminal statutes, as exemplified by the recent case of the Illinois nursing homes owner mentioned above. Those convicted or who plead out can face prison time as well as hefty criminal fines and penalties, all on top of civil damages.

This recent case in Illinois and so many others highlight the importance of these federal laws in combating waste, fraud and abuse, and most importantly protecting patients from the greedy and overzealous actions of doctors, hospitals and nursing homes. All of those in nursing homes and with loved ones in nursing homes should be aware of these fraudulent acts, their implications for patients and residents, and the importance of combating fraudsters.

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