Do you remember the game Monopoly? In the original edition there are “Chance” cards, some of which tell the player to “Go Directly to Jail, Do Not Pass Go, Do Not Collect $200.” Diana Jocelyn Gumila is headed there today. Convicted of Medicare fraud, she will be spending the next 6 years behind bars. Upon her release, Gumila must pay Uncle Sam $15.6 million in restitution. Thanks to a concerned employee – turned- whistleblower, Gumila’s days of feeding off taxpayers are over.
Gumila was arrested in 2014 after an employee alerted authorities earlier that year that Gamila was stealing from the taxpayer funded Medicare program. Her story and quick downfall brought by the brave actions of a whistleblower are worth telling.
Gumila’s Medicare Fraud Scheme
According to a 70 page FBI affidavit filed with the court, Gumila ran a home healthcare agency called Doctor at Home. The company was established to help homebound patients that couldn’t travel to medical appointments to instead receive care at home. The Centers for Medicare and Medicaid Services (CMS) prefers home care because it is usually less expensive than housing someone in a skilled nursing facility. Patients like it because they can remain in their home and retain more independence. Unfortunately, home care services are often rife with fraud.
Gumila’s company served the metropolitan Chicago area. Authorities have identified Chicago, Miami, Detroit, Philadelphia, Houston and New Orleans as being particular hotspots of home healthcare fraud.
Medicare pays for home healthcare services but only if a physician finds the patient is homebound and that the care is “reasonable and necessary.” Once certified, a physician must re-evaluate the patient every 60 days to insure they still qualify for in home services.
Despite very strict rules, Gumila gamed the system and was falsifying paperwork in order to get more money from Medicare. Doctors affiliated with the agency would falsely certify that patients needed home care even if untrue.
Not all the physicians agreed with Gumila. When when one doctor noticed that her notes had been changed she promptly quit.
Once authorities began investigating, many Doctor at Home staff began cooperating. One physician recorded a conversation in which she told Gumila that she met a particular patient after he had walked three blocks with a heavy bag of groceries. The patient also told the doctor that he had no complaints. Clearly the patient was not home bound and not in need of taxpayer funded, expensive home healthcare. In fact, the patient merely wanted a prescription refill.
Under Medicare guidelines, no home visited was warranted yet Gumila said it was okay. In fact, Gumila suggested that 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 complaint against Gumila also says that she and her agency double billed for services. A short, routine visit would be billed both as a patient visit and a separate wellness visit. In some cases, Doctor at Home staff located in the Phillipines were completing billing as if a patient needed extended care even though these staff members had not seen the patients and no such services were performed.
Employee – Whistleblower Reports Gumila
The case against Gumila was started by a whistleblower’s tip. We estimate that 80% of Medicaid fraud cases start with a tip from a concerned staff member or physician. Government auditors audit less than 1% of providers each year. There simply aren’t enough of them. That makes whistleblowers extremely important players in the war on greed and corruption.
Thanks to the whistleblower, the FBI was able to quickly investigate the case and shut down the company. Gumila was arrested within 6 months.
In April of this year, Gumila took her case to a federal court jury in Chicago. She lost on all counts and was convicted of 21 felony healthcare counts and 3 counts of providing false information. Still not satisfied, Gumila made a last ditch effort to have the jury verdict overturned. When that didn’t work, she demanded a new trial. All of her tactics exhausted, Gumila was finally sentenced this week.
Gumila’s lawyer tried to convince the judge that Gumila was only accused of a few false billings. Out of 43,584 bills, only 8 were included in the criminal complaint. Her lawyer asked for a sentence of no more than 18 months.
The government painted a very different picture of Gumila. Prosecutor Stephen Chahn Lee told the court,
“Instead of following Medicare’s rules for nursing services, she hired doctors who signed off on whatever forms they were given, lied to her staff about Medicare’s requirements, and personally authorized the signing of some improper orders. And instead of following Medicare’s rules for care plan oversight, she instructed her staff to make false documentation to bill Medicare for millions of dollars of unnecessary oversight that was not even done.
“[Gumila] did this for years, despite time after time when her employees tried to do the right thing. When doctors accurately described patients’ conditions in files as “stable” and “excellent,” she sent out memos telling them to stop using those words to avoid problems if auditors looked at the files. When doctors and physician’s assistants tried to discharge patients who did not qualify for services, she overruled some and ignored others. When employees raised concerns about the company’s compliance with Medicare’s requirements, she lied to some and kept information away from others.”
Perhaps most damning, Lee told the court, “And when she saw that the head of a similar company
arrested for similar fraud, she viewed it not as a wake-up call but as an opportunity to expand her company.”
On July 26th, Gumila was sentenced to 6 years in prison and ordered to pay $15.6 million in restitution. At sentencing 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 she used her patients like a “cash register.”
If Judge Kocaras had any sympathy for Gumila’s arguments, it wasn’t evident. He made short work of her argument about only 8 claims being proven and noted that from the testimony of the witnesses, it was clear that most of Doctor at Home’s claims were false. In our opinion, he appeared to be somewhat annoyed at Gumila’s arguments and viewed them as a failure to accept responsibility.
Given Gumila’s continued refusal to accept responsibility for her actions, we have no doubt that we will see many appeals in future months. For now, like the Monopoly game, Diana Gumila is headed for jail. In her case, a federal prison.
Medicare Fraud and Whistleblower Awards
As noted above, most Medicare fraud cases come to light because of whistleblowers. Under the federal False Claims Act, whistleblowers can receive up to 30% percent of whatever the government collects from the wrongdoers. To qualify for an award, a would be whistleblower must have inside (“original source”) information about Medicare fraud and must file a sealed complaint in federal court. Calling a toll free hotline might get you a $1000 award but not the larger percentage awards that are only available under the False Claims Act.
Medicare and Medicaid fraud are huge problems in throughout the United States. Taxpayers lose tens of billions of dollars annually because of healthcare fraud. And many truly needy patients are denied care because of fraudsters like Diana Gumila.
If you have information about Medicare or Medicaid fraud, give us a call. We love working with whistleblowers and never charge a fee unless we get collect for you. Worried about prosecuting a federal lawsuit? Don’t. That is our job. Worried about retaliation? We can also help protect your rights if you suffer retaliation.
For more information, contact attorney Brian Mahany at or by telephone at (414) 704-6731 (direct). All inquiries are protected by the attorney – client privilege and kept confidential. Not quite ready to call? We understand. Feel free to download our 11 step guide to blowing the whistle. You don’t need to give us your name, phone number or email.
MahanyLaw – America’s Medicare Fraud Whistleblower Lawyers