Caring Nurse and Good Quality: The Recruiter Brought the Paperwork Too

The owners of Caring Nurse and Good Quality admitted to a scheme using recruited patients and false care files involving approximately $48 million in claims and approximately $33 million in Medicare payments, according to the Justice Department’s account of their criminal guilty pleas. Recruiters supplied patients and certification documents, while agency staff falsified files supporting unnecessary or unprovided care.

The owners of Caring Nurse Home Health Corp. and Good Quality Home Health Inc. pleaded guilty in December 2012. The agencies’ combined billing and payments covered January 2006 through June 2011. For an intake worker, nurse or biller, the revealing detail is what arrived with the patient: the paperwork used to support Medicare billing came through the recruitment channel too.

The Recruiter’s Handoff Reached Into the Clinical File

The distinctive feature of this patient recruiter fraud was that recruiters supplied certification documents along with patients. Their role reached into the paperwork supporting the agency’s claim to payment. Staff then supplied another part of that support by falsifying care files.

In home health, the referral, certification, assessment and plan of care serve different purposes. A referral brings someone to an agency. The certification addresses Medicare eligibility, including homebound status and skilled-care need. The assessment describes the patient’s condition, and the plan identifies the care to be provided. That certification chain is supposed to connect the patient’s needs to the agency’s work.

An intake employee may know who brought in the certification material. A clinician may know whether the patient needed the services described. An office employee may know who made the file say something else. We connect those accounts because the completed packet can conceal the decisions that produced it.

Recruiters brought the patients and the certification papers. Staff made the care files fit. The paperwork agreed with the business it was supporting.

False Care Files Made the Billing Story Work

Staff at Caring Nurse and Good Quality falsified files supporting unnecessary home health care or care that was never provided, according to the owners’ plea account. Those are different ways for the clinical story to fail. One concerns whether the patient needed the service. The other concerns whether the service happened.

The clinical findings describe the patient’s needs. The plan describes the intended care. Visit documentation describes what staff say they delivered. A false statement in any of those places can make a claim look supported while concealing a different account of the patient or the work.

For agencies operating today, Medicare requires medical records supporting the patient’s eligibility and a plan identifying the care to be provided. In a healthcare business, those records should describe the patient, not serve the billing target.

A separate criminal prosecution involving Patient Choice Home Healthcare Inc. and All American Home Care Inc. shows another way a convincing-looking file can be manufactured. The Justice Department’s account of the trial evidence described beneficiary-signed blank forms turned into fictitious therapy records. The signature came from the patient. The account of the therapy came later. That sequence matters to anyone who saw a form before and after it became a clinical record.

How False Files Reached Medicare Payments

The billing and payment records show where a false care file reached Medicare’s money. A submitted claim shows what the agency sought. The remittance shows what Medicare actually paid after adjustments. Connecting those records to the care file lets us follow a false statement into a particular payment.

Medicare paid for the care described in the files. Staff had falsified the account of that care. That is the taxpayer’s stake in health care fraud that can look, inside an office, like a paperwork task.

What Evidence Is Needed to Prove Fraud?

For a case involving recruited patients and false care files, the useful evidence connects how the patient arrived, what the clinical records said, what care occurred and what the agency billed. We work through those connections with the insider who knows the business and can explain the instructions behind the records.

An intake or referral employee may recognize who supplied a patient’s documents and how they reached the agency. That account can explain the source of material that later appears in a clinical file without its recruitment history.

A nurse or therapist may know the patient’s actual condition and the services delivered. An office employee may know who created or changed an entry. We examine how the file was made with you, including who directed the work, instead of treating the final record as the whole story.

The Medicare claims workflow brings clinical and assessment information into payment processing, with remittance showing the amount paid. A biller’s knowledge can explain which services the agency claimed and which payments followed.

Those records can sit with different people. Your view of the referral, the patient’s care or the billing may explain a connection that is hard to see from the finished documents alone. Our role is to build the case around that knowledge, including who knew the records were false and how they were used.

The Office Can Be Where a Whistleblower Sees It

A receptionist brought the qui tam case involving GreatCare, another home health agency accused of billing for unnecessary or unperformed visits. The Justice Department’s civil case account described alleged beneficiary recruitment and payments to beneficiaries and physicians for referrals. A court ordered the agency’s owner to pay $14,902,832 in the civil case.

GreatCare shows why an administrative employee’s knowledge can matter in a case about clinical services. The office can be where referrals, patient records and billing meet. A person who knows how those pieces came together can explain more than someone reading the claim after payment.

The Caring Nurse and Good Quality owners’ criminal admissions likewise put agency staff inside the account of how false files supported billing. That is the part an employee may recognize in another agency: the instruction to make the record fit the service being claimed. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know How the File Was Made

If you saw recruitment documents become a false care file, or know who instructed staff to make the records fit the billing, speak to one of our Whistleblower Experts about what happened inside the agency. We develop the case with you, bring in home health fraud whistleblower lawyers who understand the connection between referrals, clinical records and Medicare claims, and stay beside you throughout the case.