Illinois Home Health Care Nurse Charged in $20 Million Fraud Scheme

A registered nurse who operated an Illinois-based home health care agency was arrested Tuesday on federal health care fraud charges for her alleged role in a scheme that billed Medicare more than $20 million.

Diana Jocelyn Gumila, a 45-year-old licensed registered nurse in Illinois since 1991, manages Suburban Home Physicians, a company located in Schaumburg, Ill.

Doing business as Doctor At Home, Gumila was charged with health care fraud in a criminal complaint that alleges a scheme to defraud Medicare by falsely certifying patients as being confined to their home and requiring home health services, according to details provided by the Department of Justice (DOJ). 

Additionally, the complaint against Gumila alleges the scheme also included falsely increasing, or “upcoding,” claims for services; over-scheduling and double-billing patient visits, submitting false claims for providing extensive oversight of patients’ home health services, and billing for tests that were not medically necessary.

A 69-page affidavit in support of Gumila’s arrest notes Doctor At Home sends physicians and their assistants, who are accompanied and driven by a medical assistant, to visit patients in their homes. 

The company gets many of its patients from home health agencies, which refer patients to Doctor At Home so that a physician will sign a form ordering the agency to provide nursing services to the patient.

From 2013 through May 2014, more than 300 home health agencies have submitted Medicare claims stating that they were ordered by just four Doctor At Home physicians to provide home health services to approximately 4,000 patients, according to Medicare claims data cited by DOJ. As a result of their claims, those agencies were paid more than $20 million. 

The affidavit also alleges that most of Doctor At Home’s visits were billed to Medicare as if they were complicated, with the average payment for most visits approximately $120. 

As a result of the alleged double-billing, over-billing and fraudulent certification of patients that weren’t confined to the home, the company assisted these agencies in falsely billing Medicare, allegedly causing the federal program to pay more than $1,000 per month on many patients “simply so a nurse can visit once a week and conduct a basic check of the patient’s condition,” DOJ stated.

“Doctor At Home’s practices and processes regularly cause Medicare to pay more than $1,250 a month for basic maintenance of many patients who do not need such services,” the complaint alleges. 

An audio recording provided by a former Doctor At Home physician of an October 2013 meeting she had with Gumila, as well emails and documents, claims data and patient files were reviewed by investigators. 

In the recorded meeting, the physician, identified as “Physician D,” told Gumila that several patients did not qualify for certain services. Gumila then responded by telling Physician D that she was an “artist” who should “paint the picture” of each patient in a way that Medicare would accept, according to DOJ’s citation of the affidavit.

If convicted, Gumila faces a maximum penalty for health care fraud of 10 years imprisonment, as well as a $250,000 fine and restitution. 

Written by Jason Oliva