Illinois’ home health care industry rife with fraud, tainted by unscrupulous physicians
Fortunately, he lived in
Koroma took refuge in home health care, a lucrative and growing industry rife with fraud and tainted by unscrupulous physicians who travel to patients' homes in search of profit, then bleed money from taxpayer-financed programs.
The down-on-his-luck doctor took advantage of this loosely regulated world to exploit his patients and command a central role in a multimillion-dollar taxpayer swindle that breached the homes of 15,600 older adults getting services from a
For adults hobbled by disability or disease who want to stay out of nursing homes or hospitals, home health care services can be a godsend.
For criminals who want to tap into federal Medicare dollars, it can represent a loosely guarded bank vault.
A Tribune investigation reveals that
Even today, most anyone can own a home health care business for a
Consequently, the
Many home health companies operate lawfully and in the best interests of their customers. But fraud is so pervasive throughout the industry, federal officials say, that for every conviction like Koroma's, there are many other participants who are able to skate away.
As a result, already-vulnerable patients are put at risk.
Corrupt home health companies and complicit physicians as well as nurses secretly laced medical files with false diagnoses involving tens of thousands of
An analysis of federal court and enforcement files since 2012 shows that thousands of patients have been subjected to unwarranted procedures, therapies and tests; some were prescribed unneeded and powerful drugs.
Most victims were unaware that their medical histories were hijacked by swindlers -- there is no legal requirement to notify or warn patients when fraud is uncovered, or when providers are convicted of crimes.
Case files show that a disabled man in his 80s was denied a wheelchair by a government insurance program because a
In another case, a hospitalized man was denied a transfer to a
"These scammers are really smart," said
Sometimes, financial crimes jeopardize patients' lives.
Yet her traveling physician,
DeHaan pleaded guilty this year to two counts of felony health care fraud related to collecting
Three months after DeHaan's arrest, civil court records show, Lingelbach was examined by a new physician who delivered a devastating diagnosis: advanced-stage lung cancer.
She died months later.
A playbook for fraud
More than 300 Chicago-area home health companies hired her company, Doctor at Home, to certify that patients were homebound and required skilled nursing care. When that happened, Gumila and company owners profited through payments from Medicare, a taxpayer-funded insurance program for those age 65 and older.
Profits flowed as long as patients remain certified -- as long as nobody documented that patients were, in reality, healthy and active and did not require in-home care.
But some of Gumila's physicians were too honest. A diagnosis is a subjective decision, she often tutored. She told one physician to "be an artist" and "paint the picture" to describe each patient -- the more abstract, the better.
In a flurry of memos beginning in
Finally, in
Nowak had decertified a woman who was a long-standing patient of a
In her chart, Nowak wrote: "We met at the front of the patient's house. She was coming back from grocery shopping with very heavy bags of groceries in her both arms. She walked from the train station three blocks. No complaints about any problem."
But Gumila, 45, a registered nurse, overruled Nowak and recertified the woman as homebound, court records show.
Doctor at Home followed a standard playbook for fraud: Falsely certify patients as homebound and in need of nursing care, submit fraudulent bills to Medicare -- and profits flow.
There are few checks and balances.
Unlike most branches of medicine where physician referrals are necessary to qualify for insurance coverage, Medicare allows home health agencies to recruit patients before they are certified for care. In
Physician
The federal Anti-Kickback Statute prohibits payments to induce or reward patient referrals under Medicare or Medicaid. Nonetheless, at least 15 Chicago-area physicians have been charged or convicted of accepting or paying kickbacks involving home health patients in the last seven years, according to a Tribune analysis of federal court records.
Cabrera doled out
"I discovered that most physicians were expecting to be paid in exchange for referring patients to the home health care business," Cabrera told federal prosecutors. "It had effectively become a way of life for those physicians, and we felt we had no choice but to accede to their requests."
Gumila's scheme needed pliable physicians to make everything work.
As a condition of employment, physicians signed over control of patient files to her. Physicians' signatures were digitally scanned and applied by Gumila and her staff to medical records; doctors were often unaware what services were billed in their names, according to court records.
Assistant
And, Lee said, as other home health companies were charged with federal crimes over the years, Gumila "viewed it not as a wake-up call but as an opportunity to expand her company."
Gumila shared patient files, filled with personal details, to unlicensed accomplices based in
Doctor at Home often billed Medicare at the highest levels, a fraudulent practice called up-coding, a government audit found. A short visit generated a
Gumila was found guilty by a federal jury in 2016 of fraud that totaled
The doctor who balked at certifying a healthy patient --
She then found employment with another
Next, she lasted one day at another health care company because of pressure to commit fraud, she testified.
She landed a third job with another
Nowak, who wishes to keep details of her life private, maintains her physician's license but said she no longer works in health care.
But physician-staffing companies are exempt from the state licensing process -- and from even minimal oversight such as unannounced inspections. That's because in
Since 2012, at least 10 physician-staffing companies, including Mobile Doctors, have been federally convicted in some of
None was licensed by
Historically, physician-staffing companies played minor roles in home health care, relegated to certifying patients for Medicare.
"Physician staffing companies are not licensed as home health agencies because they are not providing home health services," a
But the Tribune found a new breed of profiteers has popped up in recent years, focused solely on home care while billing Medicare for repeated examinations, prescriptions and medical diagnostic tests.
Those types of firms can play a central role when there's fraud. The
Under the regulatory loophole, Mobile Doctors was not required to obtain a home health license or subjected to state oversight, despite conducting in-home examinations and providing diagnostic care to tens of thousands of patients across six states.
Owner Dike Ajiri, a former collegiate rugby player, rented a nondescript brick building on
His go-to physician was Koroma, one of 19 Chicago-area physicians convicted of felony home health crimes in the last five years, the Tribune found.
"
In 2012, for instance, Koroma purportedly conducted 4,176 in-home visits that spanned from 40 to 75 minutes, according to Medicare claims data. If true, Koroma visited an average of 11 patients every day, including weekends and holidays.
Federal billings also reflect Koroma's approval for 3,700 ultrasound tests, which federal prosecutors charged were largely conducted to drive up profits for Mobile Doctors.
Koroma, 68, was found guilty by a jury of two felony counts of health care fraud involving Medicare and two felony counts of making false statements; he was sentenced last year to 40 months in prison. Since he never became a
Ajiri pleaded guilty in 2015 to a felony count of health care fraud involving Medicare, was sentenced to 15 months in federal prison and ordered to pay
Even when companies are licensed as home health agencies, regulatory oversight has been needlessly fragmented between federal and state agencies, which often failed to share case information involving violations, enforcement records show.
State health department oversight focuses primarily on administrative paperwork rules and pays little attention to financial fraud, which is delegated to federal oversight.
Inspections occur every three years, long enough for home health companies to collect millions of public dollars and disappear without warning.
That's how the state issued a clean bill of health to a home health agency that is linked to a federal criminal investigation.
In 2013, the owners of Pro
FBI officials launched an investigation. But one of the Pro Vita owners purchased the license of an existing home health agency located just 2 miles away and reopened as
State public health officials, who were unaware of the federal investigation, also searched for the whereabouts of the owners who had failed to renew the Pro Vita license.
But as one arm of the
Detection should have been easy. On the application for a new license, under previous experience, an owner and several staff members listed their years of work at the abandoned company.
As a result of the Tribune finding, public health officials said they plan to modify state regulations to require a more thorough background check on previous employment.
Each year on average, at least half a dozen home health businesses are abandoned without notice, the whereabouts of owners unknown, state records show.
Unlike other major branches of health care, which use the web to provide information on enforcement actions and surveys, oversight of
Instead, the public is required to file a formal public records request to view even basic information about a home health business, such as ownership, enforcement history and quality rankings. Requests can take weeks to fill.
The Tribune filed multiple requests to obtain even aggregate statistics, such as how many surveys and complaint investigations are conducted each year.
Each year, health department officials survey about 163 businesses and conduct 53 complaint investigations. Officials substantiated minor violations, on average, in less than 1 in 5 cases, which were resolved with written plans of correction.
A department spokeswoman acknowledged that "no major enforcement actions have been taken against home health agencies" in the last five years.
Feds overwhelmed
The once-moribund home health industry burst to life in 2007 as government programs shifted funding to "aging in place" strategies as a way to shorten or avoid costly hospital and nursing home admissions.
By 2013, as new home health companies flooded into
"Health care fraud has been a significant problem in
Today,
Significant federal resources are now focused on home health fraud in
In the last seven years, home health care fraud charges have been filed against 96 people -- including physicians, nurses, recruiters and owners -- involving two dozen home health or physician staffing companies throughout the
Nonetheless, federal studies show, the rate of fraud remains dauntingly high. Marshaling limited resources, prosecutors often focus on the most blatant violators. But hundreds of smaller co-conspirators have gone free so far, the analysis shows.
At least 357 active home health companies in the
This isn't just a
But it's not just resources that are at issue; federal regulations play a role in making home health fraud so tempting.
Under Medicare, home health companies can bill in advance for a portion of estimated costs of patient care. Accounts are later reconciled, but it can take years for federal auditors to catch up to savvy crooks.
In an effort to thwart false claims, federal officials in 2016 ordered
"We support the moratorium. We want more enforcement," said Executive Director
But the government's reform unfairly punished legitimate businesses, she said, akin to disciplining the whole class for the actions of one student.
The reform measure also encountered fierce bipartisan resistance from Florida
Then-
With the failure of billing reform, it's up to prosecutors and the licensing moratorium to stave off fraud.
But if the moratorium was meant to prevent new operators from entering the field, it's falling short. Existing licenses -- and the patients that come with them -- are routinely brokered over the internet.
"Do you desire to own a Home Health Care in the
How the Tribune conducted its investigation
To examine the home health care industry, the Tribune first obtained licensing information for 819 private home health companies from the state
Licensing files were supplemented by research that included public record requests for survey reports, complaint investigations and enforcement actions.
The Tribune also gathered seven years of federal court cases from
The Tribune also analyzed millions of patient billing claims obtained from the Centers of Medicare & Medicaid Services, a division of the
Medicare data are differentiated through the use of alphanumeric codes under the Health Insurance Prospective Payment System, or HIPPS. The Tribune analyzed data with 10 different codes that tracked in-home physician visits with new and established patients. Three other codes were used to determine how often physicians billed, and for how much, to certify patients for home health care or to review patient files.
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