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Chicago Filipino nurse faces 10 years for $20M Medicare fraud

Doctors at Home

Home health care company nurse manager Jocelyn Gumila worked for; she was convicted of Medicare fraud. PINOY

CHICAGO—Diana Jocelyn Gumila, 46, faces up to 10 years in federal prison and a mandatory $250,000 fine and restitution after she was found guilty April 17 on 21 counts of Medicare fraud and three counts of making false statements pertaining health care.

Gumila was convicted after a two-week jury trial on the charges filed against her as head of a home health company in Schaumburg, Illinois, a suburb 32 miles northwest of this city. Her sentencing is set on July 26.

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An Illinois registered nurse since 1991, Gumila was the manager of “Doctor at Home” and was indicted on August 2014 along with Alan Newman, a physician from Chicago, and James Ademiju, a nurse from Matteson, Illinois, who had been previously convicted on charges stemming from the probe, federal authorities said.

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Prosecutors led by Stephen Chan Lee told the court that Gumila led 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.

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According to 2014 original 69-page affidavit in support of the arrest, search and seizure warrants, Doctor At Home sent physicians and physician’s assistants, who were accompanied and driven by a medical assistant, to visit patients in their homes.

Doctor At Home got many of its patients from home health agencies, which refer patients to Doctor At Home so that a physician would sign a form ordering the home health agency to provide nursing services to the patient.

$20 million

According to Medicare claims data, from 2013 through May 2014, more than 300 home health agencies had 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.

Government lawyers also said 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 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 $1,250 a month for basic maintenance of many patients who do not need such services.

In 2014 before charges were filed, federal agents had interviewed one current and seven former employees of Doctor at Home, including a physician’s assistant who contacted law enforcement in January 2014.

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Investigators had 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 e-mails 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 who began working for Doctor At Home only a few weeks earlier in 2014, told Gumila that several patients did not qualify for certain services. Gumila responded by telling the doctor that she was an “artist” who should “paint the picture” of each patient in a way that Medicare would accept, the jury was told.

Gumila 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 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.

Double-billed

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.

Doctor At Home 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.

The investigation was conducted by the Medicare Fraud Strike Force, which is part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the U.S. Justice Department and the U.S. Department of Health and Human Services. 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.

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TAGS: Diana Jocelyn Gumila, Doctor At Home, double-billing, fake medical claims, Health Care Fraud Prevention & Enforcement Action Team (HEAT), home health care fraud, Medicare, Medicare fraud, Medicare Fraud Strike Force, prosecutors led by Stephen Chan Lee, U.S. Department of Health and Human Services, U.S. Justice Department, Xpress Mobile Imaging
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