evidence sheet with money in it
(Credit: Peter Dazeley / Getty Images)

A $40 million Medicare fraud scheme involving assisted living communities and nursing homes includes the submission of thousands of false claims across several states over six years, according to the Department of Justice.

The department said Friday that it had filed a 96-page complaint under the False Claims Act against Thomas M. Prose, M.D., owner of Novi, MI-based General Medicine, alleging widespread healthcare fraud involving the submission of thousands of false claims to the Medicare program. The company employed physicians and nurse practitioners to treat long-term care residents and patients in several states, including Illinois and Missouri.

The DOJ complaint alleges that Prose and 17 of his related corporate entities had “engaged in a multi-million dollar scheme” since 2016 and “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.”

“Rather than focusing on care for the vulnerable patient population they served and treating each resident based on their individualized needs, defendants played a numbers game designed to bill as many patient visits as possible, regardless of whether those visits were actually performed as documented or medically necessary,” the complaint reads, adding that one clinician said that General Medicine “preferred quantity over quality.”

The government alleges that the false claims were submitted in multiple states, including Illinois, Kansas, Missouri, Michigan, Louisiana, Iowa, Ohio and North Carolina. The complaint notes that despite receiving numerous warnings since at least 2013 that its visits were “excessive, medically unnecessary and did not meet the requirements for the codes that were billed,” General Medicine only made changes “designed to further conceal their fraudulent practices from Medicare.”

General Medicine is accused of submitting inflated claims to Medicare using billing codes for complex, comprehensive visits when providers spent minimal time with residents and patients. On multiple occasions, progress notes containing inaccurate information or embellishments allegedly were used to bill for visits using codes with higher reimbursement rates.

The complaint notes that General Medicine incentivized its clinicians through compensation to perform as many visits as possible, establishing quotas and tying bonuses to additional visits.

Related to this Medicare fraud investigation, Jami Mayhew, a former General Medicine nurse practitioner, previously pleaded guilty to healthcare fraud, and Phillip Greene, a former General Medicine physician, was indicted in September. 

“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 quotes,” U.S. Attorney Steven D. Weinhoeft said in a statement

The Medicare fraud investigation involved the U.S. Attorney’s Office for the Southern District of Illinois, the U.S. Department of Health and Human Services Office of Inspector General, the Illinois State Police Medicaid Fraud Control Unit, the Federal Bureau of Investigation, the U.S. Department of Labor Office of Inspector General and Employee Benefits Security Administration, the U.S. Postal Inspection Service and the Department of Defense Office of Inspector General.