On December 2nd, Atlanta-based home healthcare owner Diandra Bankhead was sentenced to over five years in prison for Medicaid fraud.

Bankhead, owner of Elite Homecare, admitted to numerous wrongful acts, including submitting more than 5,400 fraudulent claims to Georgia Medicaid. Out of the $1.2 million Bankhead received in reimbursement, $1 million was deemed to be fraudulent.

In order to submit more claims, Bankhead became a Georgia Pediatric Program (GAPP) provider through false credentials and paperwork. Bankhead falsely represented that a registered nurse was overseeing the services administered while also stating that an RN supervisor was performing initial evaluations for potential members.

The Georgia Pediatric Program is a state-funded initiative that serves vulnerable children under the age of 21. Children who typically receive care under GAPP have significant cognitive and physical disabilities that require skilled nursing services.

During Bankhead’s hearing in August of 2019, she admitted to submitting thousands of fraudulent claims between September 2015 and April 2018. These claims included billing for services that were never administered as well as filing claims for children who were never even seen. She also submitted reimbursement requests in which her employees allegedly provided more than 24 hours of services in a given day. Other claims included employees aiding multiple children at the same time. In addition, Bankhead stated that her employees provided services to an infant after the child had already passed.

The actions committed by Bankhead are common forms of Medicaid fraud, but they are not the only ways providers can be charged with fraud. According to Art Kalantar, a California attorney who advises healthcare providers on healthcare law and defends medical professionals charged with fraud and abuse, Medicare and Medicaid fraud also include practices such as Unbundling (billing for multiple procedures codes (CPT codes) for a group of procedures that are covered in a single global billing code); Upcoding (billing for services at a higher level of complexity than provided); Kickbacks (offering, accepting, soliciting, or paying for beneficiary referrals for medical services or items); Collusion (knowingly collaborating with beneficiaries to file false claims for reimbursement); Drug Diversion (writing unnecessary prescriptions or altering prescriptions to obtain drugs for personal use or to sell them); and Card Sharing (knowingly treating and claiming reimbursement for someone other than the eligible beneficiary), among others.

“A Medicare and Medicaid provider is required to be familiar with the relevant federal and state laws that govern Medicare/Medicaid programs,” says Kalantar. “Ignorance of laws is generally not a valid defense.” Kalantar states that in his experience, providers sometimes genuinely believe that a certain business practice is legal when in fact it is not. “Providers should know,” he explains, that “what may be a legal transaction in a regular business setting may be a criminal one in a healthcare business.” Kalantar adds it is important for a healthcare provider to obtain legal advice and guidance from a qualified healthcare attorney with a strong understanding of billing and coding laws and regulations, Stark Law violations and allowed safe harbor exceptions, and other vital areas of healthcare law.

Not only did Bankhead falsify claims to receive reimbursement, after further investigation, authorities found that she had partnered with another Atlanta-based home health provider to increase her profit. Bankhead gave this company twenty of Elite’s former clients in exchange for a percentage of the Medicaid reimbursement associated with those clients.

After an investigation by the Department of Health and Human Services, the Georgia Medicaid Fraud Control Unit, and the Federal Bureau of Investigation, Bankhead was sentenced to five years and three months in prison for one count of healthcare fraud. She was also sentenced to pay $999,999 in restitution.

Special agent in charge of FBI Atlanta, Chris Hacker, stated that “the greed of this defendant deprived health care to many at risk children in Atlanta, focusing on profit rather than the care of our kids. The FBI will not stand by and allow those who commit fraud to take advantage of programs that are intended to support our state's most vulnerable citizens.” While taking advantage of the welfare system is not a new practice, officials have used this case to exemplify their commitment to cracking down on Medicaid fraud.