GreatCare: The Receptionist Kept the Case Going

The GreatCare fraud judgment ordered the agency’s former owner to pay $14,902,832 in a Medicare case alleging thousands of home health visits that never happened or were medically unnecessary. The Justice Department put the scheme at $5 million, with the judgment approximately three times Medicare’s losses. A receptionist brought the False Claims Act case and pursued it after the government declined to take it over.

GreatCare Home Health Agency operated in the Westlake District of Los Angeles. Its owner was a registered nurse. The owner’s separate criminal plea supplied admissions about how that business worked, down to false records and services attributed to people who never provided them.

Paid Referrals and Visits That Never Happened

The whistleblower’s lawsuit alleged that GreatCare recruited Medicare beneficiaries and paid both beneficiaries and physicians to generate home health referrals. It alleged that the agency then billed Medicare for thousands of visits that were unperformed or medically unnecessary.

Medicare payment for home health care depends on the patient’s eligibility, need for skilled care, plan of care and supporting records. The visits documented in the file are supposed to connect the ordered care to the claim. GreatCare’s case reached across that process: how patients arrived, what their records said and what the agency charged Medicare. A receptionist can see the arrangements behind a referral alongside the paperwork behind a visit.

What the Owner Admitted in Her Criminal Plea

In her criminal plea agreement, the owner admitted orchestrating payments to doctors, marketers and patients, according to the Justice Department’s January 12, 2012 announcement. Doctors and patient recruiters, known as cappers or marketers, received kickbacks for referrals. Patients received payments to sign up for home health services.

The same plea account says she admitted billing Medicare for patients who were not homebound or otherwise did not qualify for home health. It also describes billing for services performed by unlicensed people and services never performed at all. The scheme targeted elderly, primarily Korean Medicare beneficiaries.

The owner admitted creating bogus medical records to support fraudulent claims and exaggerating patients’ conditions to obtain larger Medicare reimbursements. Those admissions explain how the referral business became a billing business. The records supplied the apparent reason to pay for the patients and services the agency had assembled.

We see the absurdity in that arrangement: pay people to become patients, then manufacture the medical story that makes Medicare pay for them. The paperwork was part of the product.

A staff nurse separately pleaded guilty and admitted preparing false forms to justify home health services. She also admitted falsely claiming visits she knew had been performed by unlicensed people or had never happened. The announcement attributes $1.1 million in Medicare payments to that nurse’s conduct.

What Evidence Is Needed to Prove Fraud?

That is what we work out with you, using your knowledge of the agency and the records behind its claims. In GreatCare’s case, the owner’s and nurse’s criminal admissions described false medical records, paid referrals and visits that never happened. The civil case began with an administrative employee who knew the business from inside.

An employee may know the instruction behind a changed record or why a visit entry conflicts with the work actually done. That knowledge gives the paperwork meaning, whether the concern is missing visits or OASIS upcoding in an agency today. We build the case with the insider who can explain those decisions.

The Receptionist Pursued the Case Without a Government Takeover

The receptionist pursued the GreatCare case after the United States chose not to take over the lawsuit. Federal officials still participated actively in settlement negotiations and coordinated with the whistleblower’s counsel.

The Justice Department says the receptionist’s lawsuit prompted the criminal investigation. FBI and Department of Health and Human Services Office of Inspector General agents searched GreatCare’s office in March 2011, when the agency shut down. The same agencies investigated the civil case.

The Judgment and the Money Transferred

The Justice Department announced the civil outcome on September 18, 2013, when the U.S. Marshals Service transferred $1,297,958 to the United States Treasury toward the owner’s judgment. The same announcement described separate civil resolutions with a referring physician, a physical therapist and another referring physician.

The government alleged that the first physician received kickbacks and signed false certificates of medical necessity. He agreed to pay $217,810.

The physical therapist agreed to pay $205,000. In his separate criminal guilty plea, he admitted creating false physical therapy notes saying he had provided services to patients. Another referring physician agreed to a civil judgment requiring her to pay $1,088,799 in the civil action.

When the Plan, Visits and Billing Tell Different Stories

Other home health complaints show the same useful comparison between ordered care, recorded care and billing. A whistleblower alleged that Amedisys changed a patient’s plan to include skilled nursing visits, performed none after the initial assessment and nevertheless billed the United States. That allegation appears in the Amedisys complaint’s account of the changed care plan.

In a separate complaint concerning Visiting Nurse Service of New York, the whistleblower alleged that a patient with a lower limb amputation had a plan calling for rehabilitation and nursing visits. The complaint then put the missing care beside the payment:

The point of that comparison is the patient’s care. The plan describes what the patient was supposed to receive. The visit history describes what the agency actually delivered. Payment makes the shortfall a billing question as well. GreatCare’s alleged nonexistent visits and its staff’s admitted false documentation make that comparison just as important inside an agency’s office as at the bedside.

A Receptionist’s Knowledge Can Matter

GreatCare’s civil case began with its receptionist, while the admissions described decisions by the owner and work performed by clinical staff. Someone who understands the office’s routines can explain a false entry, a recruitment arrangement or an instruction that looks ordinary on paper. We turn that firsthand knowledge into a healthcare fraud case built around the claims and the people responsible for them. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What Happened Behind the Visit Entry

If the referrals, visit records or billing inside your agency tell a different story from the care patients received, speak with our whistleblower experts about the visits and payments you know. We build your strongest home health whistleblower case around that knowledge, bring in home health fraud whistleblower lawyers who understand referral payments and false visit records, and stay beside you as the case moves forward.