Updated on: June 22, 2012

Doctor, Home Health Agency Owner Plead Guilty in Fraud Scheme

By
Original story posted on: May 10, 2012

alert-powered-by-decision-health

 

A fraud bust in the Detroit area nabbed a home health agency owner and a doctor in connection with a $13.8 million scheme.

 

Zahir Yousafzai, owner of First Care Home Health Care and Moonlite Home Care, pleaded guilty to conspiracy to commit health care fraud and money laundering. Dr. Dwight Smith pleaded guilty to conspiracy to commit healthcare fraud, according to the Justice Department.

 

Yousafzai, who also helped operate Physicians Choice Home Health Care and Quantum Home Care, billed with co-conspirators about $13.8 million in fraudulent home health claims for services they never provided from July 2008 to September 2011, the Justice Department stated.

 

He also paid kickbacks to recruiters so he could use the information to submit claims for services that weren't provided, the Justice Department stated.

 

In September 2009, Smith started referring beneficiaries to the home health agencies, the Justice Department stated. He employed people who claimed to be doctors to examine Medicare beneficiaries who were not homebound, a requirement for home health care, and were paid to sign patient visit forms. Medicare paid about $6.5 million for fraudulent home health claims based on Smith's referrals.

 

In a separate case in South Dakota, podiatrist Todd Monroe will pay almost $242,000 after pleading guilty to making false statements relating to healthcare matters.

 

"Monroe rendered routine non-reimbursable services, such as cutting toe nails or removing corns or calluses, then falsified the patient's medical record and improperly billed Medicare for surgical procedures," according to the U.S. Attorney in South Dakota.

 

RACs Release Four Issues

In recovery auditor (RAC) news, Region A RAC DCS Healthcare Services posted two issues about MRI scans for specific states in its area. Region B RAC CGI Federal posted two outpatient issues. See the chart below for more details.

 

Critical access hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

MRI scans

5/7/12

N.Y.

Potential incorrect billing of MRI scans not supported by medical necessity

Social Security Act section 1862(a)(1)(A); NGS LCD L28518; NGS article A48016; CMS Pub. 100-03, chapter 1

 

Physicians/non-physician practitioners

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

MRI scans

5/7/12

Conn., N.Y.

Potential incorrect billing of MRI scans not supported by medical necessity

Social Security Act section 1862(a)(1)(A); NGS LCD L28518; NGS article A48016; CMS Pub. 100-03, chapter 1

 



 

Outpatient

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Hyperbaric oxygen therapy correct coding

4/25/12

RAC Region B

Establish edit parameters and workflow guidelines to identify claims that have been incorrectly reported for hyperbaric oxygen therapy. Claims for HBO of the treatment of diabetic wounds of the lower extremity require documentation of dual diagnoses. An ICD-9-CM code from either the 250.70-250.73 range or the 250.80-250.83 range (representing a diabetes-related problem) plus one of the following ICD-9-CM codes: 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, or 707.19 (representing a lower extremity wound) must be reported.

CMS Pub. 100-04, chapter 32; CMS Pub. 100-03, chapter 1

Outpatient Zoledronic Acid (Reclast®)) 1 mg - Units billed versus units reported

4/25/12

RAC Region B

Establish edit parameters and workflow guidelines to conduct an automated review to identify incorrect number of units billed for covered/allowed services of Zoledronic Acid (Reclast®) 1 mg. An overpayment exists when a provider bills for greater than 5 units of service for HCPCS code J3488 for the same date of service.

CMS Pub. 100-02, chapter 15; CMS Pub. 100-04, chapter 17

 

About the Author

 

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

 

Contact the Author

 

KLong@decisionhealth.com

 

To comment on this article please go to editor@racmonitor.com

 

Best Practices for Responding to Individual Audits

 

This email address is being protected from spambots. You need JavaScript enabled to view it.