Opinion ID: 4240390
Heading Depth: 4
Heading Rank: 1

Heading: The certifying physician himself or herself.

Text: (2) A physician, with privileges, who cared for the patient in an acute or postacute care facility from which the patient was directly admitted to home health. (3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health. (4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges 15 Case: 16-31119 Document: 00514327885 Page: 16 Date Filed: 01/30/2018 No. 16-31119 The Government also presented evidence that Dr. Ganji signed blank certification forms and posited that she did so in order to assist Christian in carrying out its fraudulent practice. When confronted with the signed blank forms, Dr. Ganji testified, Usually [there] is a sheet preceding this sheet that is the face-to-face encounter. And then preceding these sheets, I have notes from the nurse practitioners. And I also have paper charts from different hospitals or the primary care physicians and also Christian Home Health Services. So preceding these sheets, there are several documents that I would have reviewed. In an additional effort to compare Dr. Ganji’s practice to Dr. Murray’s, the Government asked Dr. Ganji about her failure to keep and maintain personal records for each patient. To this, Dr. Ganji responded, “Christian Home Health kept all the records of OASIS and the nurses’ documentation. It was brought to me whenever they brought the 485s, paper charts were brought to me.” Dr. Ganji indicated that she kept records for patients for which she was the PCP, but Christian kept records of those patients for whom she was the attending physician. The Government did not rebut this testimony which aligns with a reasonable interpretation of the regulations which requires “[t]he provider must obtain the required certification and recertification statements [and] keep them on file for verification by the intermediary, if necessary.” 42 C.F.R. 424.11(a). From this evidence a reasonable juror could not infer beyond a reasonable doubt that Dr. Ganji agreed to commit health care fraud. who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health. (5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health. 42 C.F.R. 424.22(a)(v)(A). 16 Case: 16-31119 Document: 00514327885 Page: 17 Date Filed: 01/30/2018 No. 16-31119 Here, the Government relied solely on inferences to support the fraud charge and attempted to use those same inferences to support a larger agreement. The Government’s theory, void of testimonial support, was that because Dr. Murray held the same position as Dr. Ganji, they must have conducted their practices similarly. The trial record rebuts the Government’s theory and amply shows that these two physicians, who carried out private practices in two different locations, conducted those practices differently. The Government only presented evidence of Dr. Murray’s illegal activity. On these facts alone, the Government cannot sustain its burden against Dr. Ganji. These inferences and the remainder of the record are insufficient to support Dr. Ganji’s conviction beyond a reasonable doubt. Exhibit 133, created by statistician Michael Tabor, illustrated the percentage of Christian patients Dr. Ganji referred to home health care. The Government emphatically points out that before Dr. Ganji became a medical director, she was only responsible for 0.25% Christian’s referrals, but that number jumped to 26% after she became a medical director. Dr. Ganji referred one patient in 2008, and 123 patients in 2010, her first year as a medical director. Although the Government depended on the jury inferring guilt from the numbers, a look at the record, including the expert’s charts and his testimony explaining how the charts were developed, reveals the meaning behind these numbers. Before Dr. Ganji was involved with Christian, she did very little business with the agency. Although she testified that she referred many patients to home health care, not many selected Christian as their agency of choice. The Government did not dispute her testimony of her past practices and did not present evidence that the total number of patients that she referred for home health care increased. The most a jury could infer from this evidence was that instead of having no preference for where her patients received care, 17 Case: 16-31119 Document: 00514327885 Page: 18 Date Filed: 01/30/2018 No. 16-31119 now that she was affiliated with Christian, she suggested her patients choose its services. One may question this practice because Dr. Ganji went from only receiving Medicare reimbursements from these beneficiaries for being their primary care physicians, to receiving multiple reimbursements coinciding with any work she did with Christian regarding the patients (e.g., certifying them for home health care, recertifying them, overseeing the medical professionals administering direct care, etc.). But this is not illegal, and it is insufficient to sustain an inference that she agreed to defraud Medicare. 10 Though not as nefarious as the Government’s preferred inference, the record substantiates that once Dr. Ganji became affiliated with a specific home health care agency, her patients followed her instead of having to establish a new doctor-patient relationship with a medical professional at a different home health care agency. Dr. Ganji spent the majority of her life practicing medicine and building her own private practice. She testified that she had extensive experience in nursing homes as well as with other home health care agencies. Here, the Government failed to present evidence that allowed any rational juror to infer the existence of a conspiratorial agreement beyond a reasonable doubt. See Miles, 360 F.3d at 478 (holding that the Government failed to present evidence allowing a rational jury to find that the defendant was a wholly illegitimate enterprise as required by the money laundering statute).