[Post Updated July 2018 – original written Dec. 2014] The U.S. Department of Justice says that Medicare fraud is on the rise in Michigan and one particular area of concern is physician house calls. Years ago, doctors routinely made house calls. Now many physicians are employed by hospital owned medical groups or clinics. Finding a doctor willing to make a house call has been tough in recent decades but that trend is starting to change. The Centers for Medicare and Medicaid Services say that Medicare spending on physician house calls has increased by 40% over the last 6 years.
While overall Medicare spending for house calls is still relatively low, the numbers have been growing each year and so has fraud. USA Today quotes U.S. Assistant Attorney General Leslie Caldwell as saying, “It’s bad. And it’s just an easier thing to do in Michigan than in other states.” Almost 20% of all Medicare spending for house calls occurs in Michigan.
As our population ages, more house calls are expected. Visiting a patient at home in many cases lowers health care costs as home visits are much less expensive than hospital stays. Patients appreciate it too. Unfortunately a few unscrupulous providers have found a new way of making a fast buck. The Justice Department claims that in recent years almost 20 physicians have been indicted in Michigan for Medicare fraud related to house calls.
Why such so much Medicare fraud in Michigan? Prosecutors say the state is just one of five that doesn’t regulate home health care. To obtain reimbursement for home healthcare under federal Medicare regulations, however, a doctor must certify a patient’s need for home care. A booming new cottage industry was created by shady doctors who make these need determinations and shady home health care agencies that bill Medicare for services never provided or are provided by unlicensed or unqualified providers.
The victims in these scams? Patients and taxpayers, of course. Because Medicare is a federally funded healthcare program, providers that rip off the Medicare system are really ripping off the public.
Senior citizens and other home bound patients are also put at risk. While some Medicare fraud scams involve billing for services never performed, other providers subject patients to unnecessary treatments or medications. Since the medical services are provided in the home, there is little oversight and that makes it much easier to conceal the scam.
Many doctors still won’t make house calls, especially for Medicare patients. The reimbursement rates are low and the government does not pay for travel time. That means a doctor can literally see a dozen patients in the time it takes to drive even a few miles to see just one patient.
While clearly concerned about the huge surge in Medicare fraud tied to house calls, Medicare officials are testing a pilot project that allows doctors to get paid more if they can show the number of hospitalizations associated with their patients decreases.
Examples of Michigan Medicare Fraud Involving Home Care
In January 2018 a Detroit area physician was sentenced to 24 months in federal prison for his involvement in a $1.7 million Medicare fraud scheme. Prosecutors say that Gerald Daneshvar M.D of Bloomfield Hills was convicted after a jury trial of conspiracy to commit healthcare fraud.
Daneshvar and two other physicians worked for a company called Lake MI Mobile Doctors. The company provided doctor’s visits to purportedly homebound Medicare patients. A jury found that while working for Mobile Doctors, Daneshvar billed Medicare for house calls that did not qualify for payment because the patients either were not sick or were not homebound.
Prosecutors also said that he would often bill Medicare for the highest paying codes for these visits, even though the visits were short or were not even necessary. Additionally, Daneshvar also referred these patients for other home health services that were unnecessary.
His co-conspirator Dr. Stephen Mason pleaded guilty to his role in the conspiracy and was given a lesser 18 month sentence. Judges will frequently give lighter sentences to those who step forward and accept responsibility for their actions. A third doctor, Leonard Van Gelder, had not yet been sentenced.
In December 2017, a Detroit jury convicted the owner of a different home healthcare agency for Michigan Medicare fraud related charges. Sixty nine year old Editha Manzano of Troy, Michigan, was convicted of one count of conspiracy to commit health care and wire fraud, one count of conspiracy to pay and receive kickbacks in connection with Medicare beneficiaries, and one count of healthcare fraud. She was the owner of Anointed Care Services, a Detroit area home health care agency.
Prosecutors convinced a jury that Manzano
“paid illegal kickbacks for patients to sign up for home health care with Anointed. The evidence further showed that Manzano conspired with physicians to admit patients for home health care with Anointed when they did not qualify for such services. To make it appear that these patients did qualify, Manzano and her co-conspirators falsified medical records and signed false documents.”
As of July, 2018, Manzano has not yet been sentenced. She faces decades in prison. (Prosecutors are asking for a sentence of 25 years. Given her age, it is tantamount to a life sentence.)
Unlike many Medicare fraud schemes, prosecutors say that patients were also victims. (Taxpayers are always victims since Medicare is financed with tax dollars.) According to a government sentencing memo,
This offense is not only about loss to a government health care program. Manzano fueled the opioid epidemic that is ravaging this community and the country by inducing addicted Medicare beneficiaries to sign-up for home health services in exchange for medically unnecessary opioids. These opioids were then either sold on the street or traded for crack cocaine. Manzano did not respect the shared humanity of all members of our society; instead, she exploited the addicted for profit.
After her conviction, the court revoked her bail pending sentencing. Her lawyer asked that she be released saying that she is not getting proper medical care for her vertigo and high blood pressure. In April, a federal magistrate judge denied her bid to be released pending sentencing. He noted that despite living here for 47 years, Manzano is not a U.S. citizen and likely faces deportation as well as a lengthy prison sentence. He also noted that a witness came forward and said that Manzano paid $2000 to kill a witness. (She has not been charged for those allegations.)
In May of this year, Roberto Quizon M.D., a physician affiliated with Manzano and her home healthcare agency, was sentenced to 18 months in prison. Dr. Quizon cooperated and pleaded guilty to a single criminal conspiracy count. Prosecutors said he was a star witness at Manzano’s trial. In their words,
Quizon testified at trial that Manzano paid him illegal kickbacks and bribes, referred to him beneficiaries who did not need home health services, fabricated documentation to make the beneficiaries appear homebound, and pressured him to certify beneficiaries for home health without actually seeing them.
Home Healthcare Fraud – Not Limited to Michigan
Medicare fraud is a huge problem in the United States and not just in Michigan. Miami, Philadelphia, Ft. Lauderdale, Dallas and Houston have also seen big spikes in fraudulent claims for reimbursement. The federal False Claims Act allows insiders with original source knowledge about fraud involving government programs – whistleblowers – to receive a portion of whatever monies the government collects from wrongdoers.
In 2014 year the government paid $435,000,000.00 in whistleblower awards. Medical billing clerks and honest physicians are often the best whistleblowers.
Think you have inside information about Medicare fraud? Give us a call right away. Having a good whistleblower lawyer is important. Being first to report is also important as the courts will usually only pay a reward to the first to file.
To be eligible for a cash reward, you must have inside information about a fraud against the government or a government funded program. That includes Medicare, Medicaid, Tricare and Champus.
Obtaining a reward means filing a sealed lawsuit in federal court. While the government investigates, the case remains under seal meaning it is secret. Ultimately the Justice Department must decide if they are going to prosecute, allow the whistleblower’s lawyer to prosecute or seek to have the case dismissed.
The State of Michigan and 28 other states offer similar rewards for information about state funded Medicaid fraud.
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Need more information? Visit our Medicare fraud information page or contact attorney Brian Mahany online, by email at *protected email* or by telephone at (414) 704-6731 (direct). All inquiries kept in complete confidence and protected by the attorney – client privilege.
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