Filipino Nurse Faces 10 Years in Prison for Medicare Fraud

A Filipino nurse has been convicted after she was found guilty April 17 on several counts of Medicare fraud and making false statements.

After a two-week trial, Diana Jocelyn Gumila, 46, faces up to 10 years in federal prison and a mandatory $250,000 fine and restitution on charges filed against her as head of a home health company in Schaumburg, Illinois. She will receive her sentencing on July 26.

Federal authorities said Gumila, a registered nurse in the state of Illinois since 1991, and who manages Suburban Home Physicians, doing business as Doctor At Home, was indicted in August 2014 along with Chicago physician Alan Newman, and nurse James Admiju.

Prosecutors told the court said Gumila led a scheme to defraud Medicare by falsely declaring patients as confined in their home care facilities and required home health services; falsely increasing claims for such services; overscheduling and double-billing patient visits; submitting false claims for providing extensive oversight of patients’ home health services and; billing for tests on patients that were not medically necessary.

In a 69-page affidavit issued in 2014 used as support for the arrest, search and seizure warrants, Doctor At Home sent physicians and assistants, accompanied by medical assistant to visit patients in their homes. Doctor At Home got many of its patients from home health agencies, which refer patients to Doctor At Home so that a physician would sign a form ordering the home health agency to provide nursing services to the patient.

From 2013 to mid-2014 more than 300 home health agencies had 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. Those agencies were paid more than $20 million as a result of their claims.

Prosecutors also said most of visits to Doctor At Homes were billed to Medicare appeared to be complicated cases, with average bill at $120. As a result of such overbilling and certifying patients from health services who were not confined to the home, Doctor At Home assisted home health agencies in falsely billing Medicare, resulting to paying over $1,250 a month for basic health maintenance of many patients who did not need such services.

In the recorded meeting, the doctor who began working for Doctor At Home only a few weeks earlier in 2014, told Gumila that several patients did not qualify for certain services. Gumila responded by telling the doctor that she was an “artist” who should “paint the picture” of each patient in a way that Medicare would accept, the jury was told.

Gumila overruled at least one physician and manipulated the certification of many patients as being confined to the home and requiring home health services. In doing so, she assisted home health agencies in billing Medicare for ineligible patients and medical services in exchange for Doctor At Home receiving patient referrals from the home health agencies.

As part of the scheme, Doctor At Home scheduled patient visits on a monthly basis rather than based on patient need and billed Medicare as if the visits were complicated when they were actually routine and short in duration.

Earlier in the year, a Filipino couple, also in Illinois, was also charged of a large-scale Medicare fraud, among other charges.