DOJ Sues Nursing Home Provider For Fraud in Multiple States

The nursing home provider directed staff to meet certain healthcare service quotas, regardless of whether they were medically necessary, according to DOJ’s fraud claims

The U.S. Department of Justice (DOJ) has filed a lawsuit against a multi-state assisted living and nursing home company, claiming the provider has submitted more than $40 million in fraudulent billing charges to the Medicare program.

The healthcare fraud lawsuit was filed in the U.S. District Court for the Southern District of Illinois on April 1, naming the healthcare provider, General Medicine, P.C., its owner, Thomas M. Prose, as well as seventeen related corporate entities owned by Prose, as defendants.

According to the complaint, the Department of Justice claims the Michigan based General Medicine company has submitted thousands of false medical treatment claims across several states since 2016, amounting to an estimated $40 million in fraudulent Medicare program billing.

With more than 1.4 million residents in over 15,500 Medicare and Medicaid-certified nursing homes throughout the United States, providers have a responsibility to provide proper care for the nation’s most vulnerable population, and not to exploit U.S. funding for Medicare services.

According to the allegations raised in the complaint, General Medicine, which offers assisted living and nursing home services across Illinois, Kansas, Missouri, Michigan, Louisiana, Iowa, Ohio and North Carolina, has knowingly  billed  Medicare  for  visits  with  facility  residents that  were  not  medically necessary, did not meet the requirements of the billing codes, or were not performed at all.

Specifically, the lawsuit alleges physicians at General Medicine submitted inflated claims to Medicare using billing codes for complex, comprehensive visits that require a significant amount of time by the physician, when in fact the physicians only spent minimal time with patients.

General Medicine also allegedly chose certain medical treatments for patients based solely on their higher reimbursement rates from Medicare, rather than for the patients’ health.

The Justice department accuses General Medicine of directing its physicians and nurse practitioners to meet quotas for patients’ visits and assessments each month, regardless of whether they were medically necessary.

“Vulnerable patients living in nursing homes and assisted living facilities should receive their medical care based on their medical needs, not needless visits manufactured to meet artificial corporate quotas,” U.S. Attorney Steven D. Weinhoeft stated in a press release. “Billing Medicare for unnecessary and worthless services at inflated rates drains valuable taxpayer funding from the program and ultimately harms the patients who need it most.”

The DOJ announced their investigation into the potential healthcare fraud scheme has already resulted in a former General Medicine nurse practitioner pleading guilty to healthcare fraud. The Justice Department also announced the indictment of Phillip Greene, a former General Medicine physician, in September 2021.

In 2016, the U.S. Justice Department arrested hundreds of professional medical personnel for allegedly billing nearly $1 billion for unnecessary and false medical treatments under Medicare and Medicaid plans.

The Medicare Fraud Strike Force, working across 36 federal jurisdictions, arrested 301 individuals; including 61 doctors, nurses and other licensed medical professionals, for their alleged participation in healthcare fraud related crimes totaling approximately $900 million in false and unnecessary treatment, prescriptions, and medical healthcare services.