The former operator of a Shelby County home healthcare agency faces charges of TennCare fraud and theft of property following an investigation by special agents with the Medicaid Fraud Control Division (MFCD) of the Tennessee Bureau of Investigation (TBI).
In June 2022, TBI’s MFCD special agents received a fraud referral from the TennCare Office of Program Integrity, alleging overbilling by the owner of a home healthcare company. During the investigation, agents determined that, from July 2018 through August 2021, the operator knowingly billed TennCare for home healthcare services provided to patients who were actually receiving treatment in area hospitals. This resulted in the loss of thousands of dollars to the State of Tennessee.
In April 2025, a Shelby County Grand Jury returned an indictment charging the operator with one count each of TennCare Fraud ($2,500–$10,000) and Theft of Property ($2,500–$10,000). She was apprehended on October 14 and booked into the county jail.
Compliance Perspective
Issue
It is illegal to knowingly submit false or fraudulent claims to Medicaid, including billing for services not provided or rendered to ineligible patients. Providers are responsible for ensuring that claims submitted are accurate, supported by documentation, and reflect care that was actually delivered. Billing for services when patients are not present, such as during hospital stays, may be considered fraud. To avoid this, facilities must have effective internal controls to prevent, detect, and correct improper billing. Oversight of documentation, patient status, and service delivery is essential to ensuring compliance with Medicaid billing requirements.
Discussion Points
- Review your organization’s policies and procedures related to service verification, documentation, and billing practices. Ensure controls are in place to confirm that services billed are both appropriate and actually delivered. When evaluating policies, organizations may benefit from working with an external consultant who can help identify gaps and offer recommendations aligned with current regulatory expectations.
- Provide targeted training to staff on documentation requirements, billing integrity, and recognizing scenarios that could result in improper claims. Training should emphasize the importance of verifying service delivery and patient status prior to billing. Med-Net Academy offers the course Fraud Series Module 7 – Auditing, Monitoring, Responding, Investigating, and Litigating, which discusses how organizations demonstrate compliance through internal audits and monitoring, outlines response protocols for compliance issues, and describes steps to take when potential investigations arise.
- Conduct routine audits of service delivery records and billing claims to verify that billed services were appropriate and actually rendered. Consider using a consultant to conduct focused or modified mock surveys to identify potential vulnerabilities in billing and documentation workflows. These reviews can help ensure policies are being followed and support ongoing compliance with state and federal regulations.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*