Declaring no sympathy for healthcare providers that commit Medicare and Medicaid fraud, a federal judge in Chicago sentenced an Illinois woman to six years in prison after a jury convicted her of 24 counts of healthcare fraud and related felonies. Like most healthcare fraud cases, the case began with a tip from a whistleblower who first reported the fraud in January of 2014.
Chicago's Diana Jocelyn Gumila and Doctor at Home
The FBI obtained an arrest warrant against Diana Jocelyn Gumila in July of 2014. According to a 70 page affidavit filed with the court, Gumila was the operator of a home health care company called Doctor at Home.
Home healthcare services have long been the subject of Medicaid fraud investigations. In cities like Chicago and its surrounding suburbs, home healthcare fraud is a particularly serious problem.
Medicaid and Medicare only pay for home care services if a physician finds they are “reasonable and necessary.” Patients must be truly confined to home in order to qualify. These services are also subject to constant review and recertification.
Even if home care is warranted, the government has very specific rules as to the level of care given. For example, a home bound patient who needs help in bathing should receive those services from an aide and not an RN, physician’s assistant or medical doctor. The rules make sense, since Medicaid is paid with tax dollars, the government wants to insure those monies are not wasted.
According to the FBI, Gumila and her company Doctor at Home were committing healthcare fraud by falsely certifying patients as being confined at home and requiring home care services. When one of the doctors working with her complained, she said the doctor was an “artist who could make patients look on paper as if they were confined to the home even when the patients can leave their homes.”
The FBI also said Gumila would double bill for services, claiming both a patient visit and a separate “wellness visit” even though the patient was only seen once and only for a few minutes.
In some cases, the visits were billed as if a physician needed to “provide extensive oversight of patients.” Those visits allowed Doctor at Home to receive additional monies for its services. In actuality, often there was no need for extensive oversight. Worse, the FBI says staff located in the Philippines were writing up these claims even though they had not seen the patients and no such services were actually performed.
Illinois Whistleblower Reports Gumila
The case against Diana Gumila began in January of 2014 when a concerned employee of Doctor at Home first tipped authorities. As soon as the FBI began investigating, other workers and physicians affiliated with the company also began cooperating.
Within a few months, Gumila and others associated with her had been arrested.
Gumila exercised her right to have the charges against her heard by a jury. In April she was convicted of 21 counts of healthcare fraud and 3 counts of making false statements.
Shortly thereafter, Gumila asked the court to overturn the jury’s verdict and declare her innocent. When that failed, Gumila sought a new trial. Both requests were denied. On July 26th, 2016, she was sentenced to 72 months in prison and ordered to pay $15.6 million in restitution.
In sentencing Gumila to 6 years in prison, U.S. District Court Judge Charles Kocaras told her, “This system operates on an honor system, and you put your honor off to the side.” He also said Gumila used her patients like a “cash register.”
Medicare and Medicaid fraud are huge problems in Illinois. Unfortunately, our state has one of the highest rates of healthcare fraud in the nation, particularly in the Chicago metropolitan area. Luckily, Illinois also has one of the most robust Medicaid fraud whistleblower laws in the country.
Illinois Whistleblowers Protected when Reporting Medicaid Fraud
Whistleblowers who step forward and report fraud are protected against retaliation. If a whistleblower has inside information about Medicaid abuse, he or she can also earn an award of up to 30% of whatever the government collects from the wrongdoers. In a $15+ million fraud, that could be millions of dollars.
Medicaid fraud in our state not only hurts taxpayers, it also hurts patients who legitimately need services. There is only so much money to go around. Putting money in the pockets of criminals means those that truly need healthcare often go without.
To report Medicaid fraud in Illinois, call 888-742-7248 or use our online report form. For more information on Illinois’ Medicaid fraud law, click here. Taking the first step is easy, safe and secure.