by James C. Sherlock
In the first article in this series, the author revealed the names of the medical directors of each of Virginia’s nursing homes and the hours of medical director time for each facility as reported in the second quarter of 2025.
Almost half of Virginia’s nursing homes reported zero hours from their medical directors. The author assumed they billed Medicare, Medicare Advantage, and Medicaid directly for those services. So, he checked Medicare records to get a general sense.
One physician’s records were particularly curious. This article will not reveal his name. It is really not about him. It is about the government’s woeful lack of capability to analyze and detect fraud in the nearly infinite amount of Medicare data it collects.
In CY 2018, he billed primarily for nursing home services and received about a quarter of the Medicare fees he received in 2022.
He changed his practice. He billed for very few nursing home services in 2022. All but $7,000 of his Medicare payments in that year came instead from home health-related services. It proved to be a profitable career move. Medicare paid almost $900,000 in 2022 for billing under his personal National Provider Identifier (NPI). That did not include an estimated $500,000+ more from Medicare Advantage and an unknown amount from Medicaid. Then there is private insurance.
Home health? Who knew?
