Not So Easily Fooled

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Shot of a confident mature woman looking outside trough her window while contemplating at home during the day

Doctors, nurses, and other healthcare workers are responsible for a considerable part of healthcare fraud, including overbilling or billing insurance for services that are never provided. (Isn’t it ironic and sad that the people whom the public trusts to help them stay healthy are the ones to abuse that trust?) 

The latest instance of this is Jami Mayhew of Carbon, Ill., who pleaded guilty to a felony healthcare fraud charge. Mayhew admitted to participating in a scheme to defraud Medicare for less than one month under the direction of her former employer.

Mayhew, who worked as a nurse practitioner, used her position to conduct medically unnecessary visits to nursing homes in St. Clair and Madison counties. She scheduled herself visits with nursing home residents multiple times a week, but only spent a few minutes at a time with each patient.

The patients asserted they did not request the visits and that they were very brief. (Mayhew depended on the vulnerability of the elderly to carry out this scheme. Fortunately, some of the residents weren’t so easily fooled and reported her erratic behavior. Good for them!)

Additionally, Mayhew falsified progress notes regarding the amount of time she spent with the patients and the services she performed. These notes were meant to legitimize her visits and fraudulently make it appear as if she met the Medicare billing requirements for nursing home visits. (Otherwise, she would not have been eligible to be reimbursed for her time at the nursing homes.)

Mayhew admitted to knowingly submitting 251 false claims to Medicare as part of her plea agreement. (That’s a lot of claims to submit in under one month.) The company she worked for, General Medicine P.C., not only knew about the fraud but encouraged Mayhew to falsify billings. They received over $23,000 in reimbursements from Medicare as a result of Mayhew’s numerous fraudulent billings.

General Medicine P.C. paid Mayhew $27 each time she falsified billing records and encouraged her to look for any opportunity to do so. In total they paid Mayhew $6,777 in exchange for illegally helping them increase their Medicare reimbursements. (Employees are a reflection of their leadership. In this case, they’re all simply rotten.)

Mayhew’s sentencing is scheduled for December 10, 2020 when she faces up to 10 years in prison and a $250,000 fine for the healthcare fraud charge. (Certainly, that’s more than the few thousands of dollars Mayhew was paid to become a criminal and defraud Medicare. Was it really worth it?)

Healthcare fraud costs the American taxpayer billions of dollars each year. It is only with the help of the public that healthcare fraud can be detected and prosecuted by the proper authorities. If you have witnessed or suspect nursing home fraud contact the Department of Health and Human Services’ Office of Inspector General hotline at (800) 447-8477 or through their online form.

Today’s Fraud of the Day comes from a Department of Justice press release, “Madison County Nurse Practitioner Pleads Guilty to Healthcare Fraud,” on September 8, 2020.

Jami L. Mayhew of Glen Carbon, Illinois, pleaded guilty today to a single-count felony information charging her with healthcare fraud. Facts elicited at the plea hearing established that, from May 30 to June 26, 2017, the 41-year old nurse practitioner knowingly participated in a scheme to defraud Medicare by performing medically unnecessary visits in nursing homes located in St. Clair and Madison counties.

Mayhew carried out the fraudulent scheme by seeing nursing home residents multiple times, examining them for only a few minutes at a time, generating progress notes she knew contained misrepresentations and materially false statements about the services she had performed, and falsely reporting that her visits met the billing requirements for complex subsequent nursing home encounters, when in fact they had not.

 

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.