Saturday, September 7, 2013

CEO and Physician For Illinois Company Who Billed Medicare For In-Home Patient Visits Charged With Medicare Fraud And Making False Statements Relating To Health Care Benefits


A recent case in Illinois shows that the government is investigating home health billing including in-home physician visits and home health agency and other related billings to Medicare. This case shows how a mobile doctor company and its financial ties and referrals have been investigated.

On August 27, 2013, the CEO of Chicago-based Mobile Doctors, Dike Ajiri, which manages physicians who make house calls in six states, and Dr. Banio Koroma (one of its physicians in Chicago) were arrested on federal health care fraud charges. At the same time, federal agents executed search warrants at Mobile Doctors’ offices in Chicago, Detroit, and Indianapolis, as well as warrants to seize up to $2.568 million in alleged fraudulent proceeds from various bank accounts. The federal complaint was filed in the Northern District of Illinois. The public is reminded that a complaint is not evidence of guilt. The defendants are presumed innocent and are entitled to a fair trial at which the government has the burden of proving guilt beyond a reasonable doubt. 

The criminal complaint allege a scheme to fraudulently increase (also known as “upcoding”) Medicare bills for in-home patient visits that Mobile Doctors falsely claimed were more complicated and longer than they actually were. 
The charges also allege that Mobile Doctors’ physicians falsely certified that patients were confined to their homes, enabling home health care agencies to claim fees for additional services for patients who were not actually qualified to receive them. There are also allegations of billing for medically unnecessary tests and for services not performed by a physician. 

Mobile Doctors in Chicago arranged patient home visits and contracted with doctors who perform the visits. The physicians assigned their rights to bill and collect payment to Mobile Doctors in return for being paid directly by the company. Mobile Doctors’ website claims that its associated physicians have made more than 500,000 house calls since its inception. In addition to Chicago, the company has branches in Detroit and Flint, Michigan; San Antonio and Austin, Texas; Indianapolis; Kansas City; Phoenix; and St. Louis. 

CEO Ajiri was charged with health care fraud, and Dr. Koroma was charged with making false statements relating to health care benefits. According to a 75-page affidavit in support of the arrest, search, and seizure warrants -- which is an outline of the government's case -- agents interviewed several current and more than 25 former employees of Mobile Doctors, including some who reported allegedly fraudulent billing practices to Medicare before they were contacted by agents. 

Investigators also reviewed e-mails and documents, claims data and patient files and have conducted interviews with patients of Mobile Doctors and their primary care physicians, whose statements allegedly contradict Mobile Doctors’ billing and patient records. 

Ordering Diagnostic Tests. Mobile Doctors physicians do not perform tests such as echocardiograms but do order such tests, which are done on Mobile Doctors’ patients by employees of In Home Diagnostics, doing business as Ultrasound2You. According to Medicare records, Mr. Ajiri is a minority partner in In Home Diagnostics, which is located in the same building as Mobile Doctors, and Mobile Doctors bills the echocardiograms so that they appear to have been done by Mobile Doctors’ physicians. Any referrals will be closely scrutinized for medical necessity and whether there is any violation of the anti-kickback/referral statutes.

Financials. The financials were key to the government's investigation as well. The complaint affidavit states that Mr. Ajiri signed a personal financial statement on December 31, 2012, stating that he received $1.5 million in annual partnership income from a corporate entity, Mobile Doctors LLC, which has a complex ownership structure involving Mr. Ajiri and, over time, one or both of his parents. Between 2008 and January 2013, bank records show that approximately $4.365 million was transferred from Mobile Doctors to an account in the name of Mr. Ajiri and his wife. 

Interviews With Former And Current Physicians, Employees and Patients Regarding Upcoding. The affidavit alleges there was upcoding and that according to interviews with former and current Mobile Doctors physicians, branch managers, clinical coordinators, employees, and patients, a typical visit that a Mobile Doctors physician has with an established patient lasts 10 to 30 minutes and is routine in nature. In contrast to those interviews, claims data shows that from 2006 through February 2013, approximately 99 percent of all established-patient visits by Mobile Doctors physicians were billed to Medicare using either of the two highest codes indicating the visits involved medical decision-making of moderate to high complexity, detailed or comprehensive interval histories or medical examinations, and/or visits that typically last at least 40 minutes. In 2009 in Chicago, the local Medicare fee for a visit using the second-highest home visit code was approximately $122.82, while the fee for the highest code was approximately $171.25. 

Claims Data Analysis For Billing Codes. The agents conducted a review of claims data for Railroad Retirement Board patients, and allege that every single established-patient visit Mobile Doctors billed to Medicare between January 2007 and June 2008 used the highest fee code. It is also alleged that between January 2007 and November 2012, approximately 93 percent of such visits were billed using the highest fee code. 

The former manager of Mobile Doctors’ Chicago branch until she was terminated in 2008 told agents that Mr. Ajiri told her that the second-highest fee code was the default code for a patient visit so that it would be worth the gas and time spent. The manager said Mr. Ajiri told physicians, “I don’t pay for ones or twos,” referring to the two lower of the four applicable fee codes. At the end of one day, she said she saw Mr. Ajiri in his office “automatically” altering the billing codes and marking visits at the highest fee level on patient records submitted by physicians and assistants who accompanied them on home visits. 

Interview With Physician. A physician told agents that in late 2007, Mr. Ajiri did not respond to his concerns about Mobile Doctors’ billing practices and instead told the doctor that he could earn more money if he would order more tests such as electrocardiograms, according to the affidavit. The complaint alleges that the vast majority of payments made on established-patient visit claims using the highest fee code were the result of fraudulent upcoding. From 2006 through 2012, Mobile Doctors received approximately $21.4 million in payments on claims using the second-highest code and approximately $12.6 million in Medicare payments on claims using the highest fee code. 

Falsely Certifying Patients as Confined to Their Homes. The charges further allege that Mobile Doctors physicians, including Dr. Koroma, falsely certified patients as confined to their homes and requiring home health services when they were not home-bound and did not require such care. By referring patients to home health agencies that did not warrant Medicare payments, Mobile Doctors received more referrals from those agencies for services provided by its physicians. According to Medicare data, from August 2010 through July 2013, more than 200 home health agencies submitted Medicare claims for services allegedly rendered to patients for whom Dr. Koroma was identified as the referring physician. These home health agencies have been paid more than $10 million for services listing Dr. Koroma as the referring physician. 

Between January 2006 and March 2013, Mobile Doctors physicians have certified or recertified for 60-day periods approximately 15,598 patients as confined to their homes and requiring home health services a total of approximately 83,133 times, many of which were allegedly false. Approximately 6,057 of these certifications were attributed since August 2007 to Dr. Koroma, with Mobile Doctors billing Medicare for approximately 17,439 patient visits he made during that time, more than any other Mobile Doctors physician. 

The health care fraud count against Mr. Ajiri carries a maximum penalty of 10 years in prison and a $250,000 fine and restitution is mandatory. The false statements count against Dr. Koroma carries a maximum of five years in prison and a $250,000 fine. If convicted, the court must impose a reasonable sentence under federal statutes and the advisory United States Sentencing Guidelines.

Posted by Tracy Green, Attorney at Law, Green and Associates
You can reach Ms. Green at 213-233-2260 or tgreen@greenassoc.com



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