A Tale of Marriage, Medicine and Murder

Have you personally witnessed Medicare fraud, and, if so, how did you handle it?


I witnessed fraudulent areas of Medicare billing during the year in which I worked for a home health agency. That year was a great experience because I enrolled in a physical assessment course at a nearby college and was taught what to look for and in my job I actually had time to practice what I was learning on real patients.

I was having trouble understanding why, as hard as we four nurses worked out of our small office, which was once a motel room, and as frugal as we were with office supplies, we always operated at a loss. The agency charge for a house call was outrageously high. We had no private-pay patients—only those on Medicare could afford us.

My husband explained that, apparently, the charge was set high so that the agency received the maximum amount of reimbursement by Medicare, which was enough to operate the agency. The agency was owned by an outfit that also operated several nursing homes and the amount we charged, which was not reimbursed by Medicare, was, apparently, claimed as a loss so that they never showed any taxable profits.

Almost all of our patients were referred to us by one physician, who ordered us to draw blood and bring it to his office for weekly tests that were run in his lab by his own lab tech. At the end of each month we met with the physician to review each patient’s condition, lab results, and meds, and to decide whether we should continue our visits for another month. If so, we readmitted him/her with another physical assessment. Our visits were two or three times a week for treatments or monitoring blood pressure or dressing changes—whatever was needed. Frequently, I found that my patients’ lab results had not been run and, even if they had been run, were not in the charts and I had to ask the lab tech for them before I could meet with the doctor, which caused me to wonder whether he was actually monitoring them.

Shortly before I left that job, I was asked by my boss to alter my assessment of a patient because Medicare would only reimburse visits aimed at teaching the patient to walk if she was physically unable to do it herself. I had charted that she was actually able to walk, just very afraid of falling. I suggested we send a physical therapist to re-evaluate her and very soon after that the hospital in which I had previously worked offered to pay me a salary and my tuition for an accelerated college program that would certify me to work in critical care—in exchange for my agreeing to work at the hospital for a specified period of time. So I became a hospital nurse again. I think the agency was as ready for me to leave as I was to go.

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Chapter 26: Chapter Twenty-Six
"... federal custody after posting a $100,000 cash bond. “Edwin York, special agent in charge of MBI’s Medicare fraud unit, says the case dramatically illustrates how some corrupt medical personnel abuse the system for their personal gain.” Oblivious to taste, Penny consumed cheese-eggs, ..."

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Have you personally witnessed Medicare fraud, and, if so, how did you handle it?

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"A nurse juggles jobs at two Mississippi hospitals, aging parents and a stressed marriage in McMillion's novel .... a comprehensive..."

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