The Department of Justice
announced Tuesday that Mary Monica Wilson-Lefler is up on one charge of health care fraud for allegedly conning nursing home patients into letting her charge insurers in their name for the special mattresses without a valid medical reason.
PPRAMS are
valid, reimbursable DME items for people suffering from multiple Stage II pressure ulcers on the trunk and pelvis, or those with a new myocutaneous flap or skin graft for such ulcers, who also meet other treatment and symptom criteria. They must also be ordered by a physician and cost
thousands of dollars.
According to the indictment, the feds believe Wilson-Lefler went around to assisted living and personal care facilities and told them Medicare had “a skin breakdown prevention program” that would pay for PPRAMS for patients with a variety of conditions that were not in fact covered, such as incontinence.
Once Wilson-Lefler had them convinced, the feds say, she filled out forms for the patients, claiming they had pressure ulcers, and sent them on to the patients’ doctors for signatures and submit the claims; when the doctors didn’t or wouldn’t sign, says the prosecution, Wilson-Lefler would forge their signatures.
In this manner, Wilson-Lefler is alleged to have billed Highmark Blue Cross/Blue Shield and Medicare $400,000 fraudulently, of which about half was actually paid. She could get 10 years in prison and a $250,000 fine.
Stay on top of the right and wrong ways to do Medicare claims at
Part B News.