In a recently released decision, the United States Court of Appeals for the Eleventh Circuit reversed the conviction of a former community mental health program director who was convicted after trial of conspiring to commit health care fraud at American Therapeutic Corporation (ATC).  According to the government, ATC, which was headquartered in Miami and had multiple locations throughout Florida, operated a brazen $200 million scheme involving purported partial hospitalization programs. Dr. Vanja Abreu was initially hired by ATC as a salaried Program Director, was promoted to Corporate Director of Utilization Review and Performance Management for a period of months, and then finished with ATC as an acting Program Director.The government alleged and the jury ultimately found that Dr. Abreu conspired to commit health care fraud by causing the fraudulent alteration of patient files, as well as therapist notes maintained in the company’s computer system, for the purpose of making it falsely appear that patients being treated by ATC qualified for partial hospitalization program treatments. According to the government, Dr. Abreu trained the staff to correct paperwork deficiencies by falsifying patient records. After being sentenced to serve nearly a decade in federal prison, Dr. Abreu filed an appeal challenging the sufficiency of the evidence against her.

Despite the government’s arguments to the contrary, the appellate court agreed that there was insufficient evidence to sustain Dr. Abreu’s conviction. The appellate court explained that while there was evidence that Dr. Abreu altered and completed patient files to make them Medicare-compliant as part of her job, most of this work occurred during mock audits. Additionally, although Dr. Abreu was responsible for ATC’s Medicare guideline compliance at all times, there was no evidence in the record that she willfully joined and participated in the alleged health care fraud conspiracy, even if she knew of it.  Accordingly, the appellate court vacated Dr. Abreu’s conviction and directed the lower court to enter a judgment of acquittal.

This case serves as a stark reminder of the importance of establishing and enforcing defensible written procedures that ensure that all patient encounters are documented in a timely and detailed manner. Allowing unfinished paperwork to pile up until billing time, overusing EMR software shorthand and cloning features, and failing to immediately correct even seemingly minor documentation errors, can be a recipe for disaster.

For any questions on this blog, please contact the author.