CHICAGO–(ENEWSPF)–July 29, 2014. A registered nurse who operates a suburban health care provider that sends physicians to patients’ homes was arrested today on a federal health care fraud charge. The defendant, DIANA JOCELYN GUMILA, who manages Suburban Home Physicians, doing business as Doctor At Home, was charged with health care fraud in a criminal complaint that was unsealed upon her arrest. The complaint alleges a scheme to defraud Medicare by falsely certifying patients as being confined to their homes and requiring home health services; falsely increasing, or “upcoding,” claims for services; over-scheduling and double-billing patient visits, submitting false claims for providing extensive oversight of patients’ home health services, and billing for tests that were not medically necessary.
Gumila, 45, a licensed registered nurse in Illinois since 1991, was scheduled to appear at 3 p.m. today before U.S. Magistrate Judge Young Kim in U.S. District Court.
Simultaneous with Gumila’s arrest, agents from the FBI, the U.S. Department of Health and Human Services Office of Inspector General, and other law enforcement agencies executed search warrants at the offices of Doctor At Home and an affiliated business, Xpress Mobile Imaging, both located in the 800 block of East Higgins Road in Schaumburg, as well as at Gumila’s residence in Streamwood. A warrant was also executed to seize alleged fraud proceeds in a bank account maintained by Suburban Home Physicians.
The arrests and charges were announced by Zachary T. Fardon, United States Attorney for the Northern District of Illinois; Robert J. Holley, Special Agent-in-Charge of the Chicago Office of the Federal Bureau of Investigation; and Lamont Pugh III, Special Agent-in-Charge of the Chicago Regional Office of the HHS-OIG. The Railroad Retirement Board Office of Inspector General is also participating in the investigation.
According to a 69-page affidavit in support of the arrest, search and seizure warrants, Doctor At Home sends physicians and physician’s assistants, who are accompanied and driven by a medical assistant, to visit patients in their homes. Doctor At Home gets many of its patients from home health agencies, which refer patients to Doctor At Home so that a physician will sign a form ordering the home health agency to provide nursing services to the patient.
According to Medicare claims data, from 2013 through May 2014, more than 300 home health agencies have submitted Medicare claims stating that they were ordered by just four Doctor At Home physicians to provide home health services to approximately 4,000 patients. Those home health agencies were paid more than $20 million as a result of their claims.
The affidavit alleges that most of Doctor At Home’s visits were billed to Medicare as if they were complicated, with the average payment for most visits approximately $120. As a result of alleged double-billing, over-billing, and certifying patients for home health services who were not confined to the home, Doctor At Home assisted home health agencies in falsely billing Medicare, allegedly causing Medicare to pay more than $1,000 a month on many patients simply so a nurse can visit once a week and conduct a basic check of the patient’s condition.
“Doctor At Home’s practices and processes regularly cause Medicare to pay more than $1,250 a month for basic maintenance of many patients who do not need such services,” the complaint alleges.
The affidavit states that agents have interviewed one current and seven former employees of Doctor at Home, including a current physician’s assistant who contacted law enforcement in January this year. Investigators have also reviewed an audio recording provided by a former Doctor At Home physician of an October 2013 meeting she had with Gumila, as well as emails and documents, claims data, and patient files, and have conducted interviews with patients of Doctor At Home and their primary care physicians whose statements contradict Doctor At Home’s billing and patient records.
In the recorded meeting, the doctor, identified as “Physician D,” who began working for Doctor At Home only a few weeks earlier, told Gumila that several patients did not qualify for certain services. Gumila responded by telling Physician D that she was an “artist” who should “paint the picture” of each patient in a way that Medicare would accept, the affidavit states.
Gumila allegedly overruled at least one physician and manipulated the certification of many patients as being confined to the home and requiring home health services. In doing so, she assisted home health agencies in billing Medicare for ineligible patients and medical services in exchange for Doctor At Home receiving patient referrals from the home health agencies. As part of the scheme, Doctor At Home allegedly scheduled patient visits on a monthly basis rather than based on patient need and billed Medicare as if the visits were complicated when they were actually routine and short in duration. Doctor At Home also frequently double-billed the same visit as a “patient visit” and also as a “wellness visit.” Doctor At Home also claimed that physicians and physician’s assistants provided extensive oversight of patients’ home health services when, in fact, employees in the Philippines prepared those oversight claims in part by counting routine visits toward oversight.
The complaint also alleges that Doctor At Home has billed Medicare for thousands of eye-movement tests that some providers believe were medically unnecessary, and it has referred thousands of echocardiograms and ultrasound tests to Xpress Mobile Imaging, which has several business ties to Doctor At Home.
Health care fraud carries a maximum penalty of 10 years in prison and a $250,000 fine and restitution is mandatory. If convicted, the Court must impose a reasonable sentence under federal statutes and the advisory United States Sentencing Guidelines.
The government is being represented by Assistant U.S. Attorney Stephen Chahn Lee.
The public is reminded that a complaint is not evidence of guilt. The defendant is presumed innocent and is entitled to a fair trial at which the government has the burden of proving guilt beyond a reasonable doubt.
The Medicare Fraud Strike Force began operating in Chicago in February 2011, and consists of agents from the FBI and HHS-OIG, working together with prosecutors from the U.S. Attorney’s Office and the Justice Department’s Fraud Section. The strike force is are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. Scores of defendants have been charged locally in health care fraud cases since the strike force began operating in Chicago.
To report health care fraud to learn more about the Health Care Fraud Prevention & Enforcement Action Team (HEAT), go to: www.stopmedicarefraud.gov.