Review and analyze the facts in the OIG press release shown in Box 8-4 . Discuss

Question

Review and analyze the facts in the OIG press release shown in Box 8-4 .

Discuss what you would do had you been the administrator of this hospice and these five nurses worked for you. if you discovered this fraud prior to the government audit, how would you handle this situation internally? be specific about what actions you would take. What might you do to prevent future staff members from perpetrating this same type of fraud at your facility?

Box 8-4:

Multi-million dollar hospice health care Fraud scheme Alleged

PHILADELPHIA - An indictment was unsealed today charging five nurses in a health care fraud con- spiracy arising from their employment at Home Care Hospice, Inc. (“HCH”), a hospice care provider in Philadelphia, between 2005 and 2008, that resulted in a multi-million dollar fraud on Medicare. Patricia McGill, 64, of Philadelphia, was a registered nurse and served as the Director of Professional Services for HCH. She allegedly authorized and supervised the admission of inappropriate and ineli- gible patients for hospice services, resulting in approximately $9.32 million in fraudulent claims. She is charged, along with Natalya Shvets, 42, of Southhampton, PA, Giorgi Oqroshidze, 36, of Philadelphia, Yevgeniya Goltman, 42, of Newtown, PA, and Alexsandr Koptyakov, 39, of Bensalem, PA, with one count of conspiracy to commit health care fraud and numerous counts of health care fraud. All five defendants were arrested this morning.

HCH was co-owned by Matthew Kolodesh, who is charged separately in an indictment unsealed October 12, 2011, and “A.P.” the Hospice Director for HCH. HCH was a for-profit business at 1810 Grant Avenue, and later 2801 Grant Avenue, in Philadelphia, that provided hospice services for patients at nursing homes, hospitals, and private residences. According to the indictment, announced by United States Attorney Zane David Memeger, McGill authorized nursing staff and supervisors, including her co-defendants, to fabricate and falsify documents in support of hospice care for patients who were not eligible for hospice care, or for a higher, more costly level of care than was actually provided to the patients. Between January 2005 and December 2008, approximately $9,328,000 in fraudulent claims for inappropriate patients were submitted to Medicare as authorized by AP and McGill. Defendants Shvets, Oqroshidze, Goltman, and Koptyakov created fraudulent nursing notes for approximately 150 patients indicating hospice services were provided for patients, when, in reality, they were not.

In February 2007, HCH was notified that it was subject to a claims review audit. According to the indictment, in anticipation of this audit McGill assisted A.P. in reviewing patient charts, sanctioning false documentation by the nursing staff, and authorizing the alteration of charts. In September 2007, HCH was notified that it had exceeded its cap for Medicare reimbursement and would have to repay $2,625,047 to the government program. At that point, A.P. and McGill directed staff to review patient files and dis- charge hospice patients. This resulted in a mass discharge of patients. In one month, 79 hospice patients were discharged in October 2007 and a total of 128 discharged by January 2008, some of whom had been ineligible for hospice or inappropriately maintained on hospice service in excess of six months. Some of the patients discharged were shifted to another hospice business owned by Kolodesh. In the Spring of 2008, approximately 20% of the discharged patients were placed back on hospice service at HCH with McGill’s knowledge. McGill is charged in 14 counts; Shvets is charged in eight counts; Oqroshidze is charged in seven counts; Goltman is charged in four counts, and Koptykov is charged in eight counts.
If convicted of all charges, McGill faces a potential advisory sentencing guideline range of 108 to 135 months in prison, a fine of up to $150,000, and a $1400 special assessment; Shvets, Goltman, and Koptykov each face a potential advisory sentencing guideline range of 27 to 33 months in prison, a fine of up to $60,000, and an $800 special assessment; Oqroshidze faces a potential advisory sentencing guideline range of 21 to 27 months in prison, a fine of up to $50,000 and a $700 special assessment.
The case was investigated by the Federal Bureau of Investigation and the Department of Health and Human Services Office of Inspector General. It is being prosecuted by Assistant United States Attorney Suzanne B. Ercole and Trial Attorney Margaret Vierbuchen of the Organized Crime and Gang Section in the Justice Department’s Criminal Division.

Source: United States Department of Justi

Explanation / Answer

As an administrator, all claims should have passed through an internal quality check before being approved and sent for claim processing. Approval of all claims should have been the authority of the chief administrator and not left alone in the hands of McGill. Regular internal audits should also have been conducted every year.

In the event that these nurses were found out during the internal audit, it is necessary to conduct an internal investigation, while suspending these nurses tilll the investigation reports come through. If found guilty during the internal investigation, then local law enforcement should be informed and legal action initiated against the 5 nurses. Termination of services should be done immediately then. Also all fraudulent claims should be reasessed to check validity again.

To prevent this from happening in future, first background checks of all nurses must be thouroughly done before hiring. The company should also have a three level check on all claims starting from the nurse to the administrator, hence all claims cannot be the sole responsibilty of a single authority but should be a combined approach. A seperate verification team should be hired privately or internally to validate the claim proposals.

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