Medicare Compliance & Reimbursement

 Why federal appeals court allowed office manager some distance from doctor's crime

How much culpability do members of the billing staff really bear if the feds dig up compliance problems?

According to a ruling upheld Jan. 7 by the U.S Court of Appeals from the 5th Circuit, office personnel who follow a doctor's unlawful billing orders should be allowed special consideration - especially if the intent to commit a fraud is unclear. 

Example: Clinic operator turned fugitive Dr. Dippakumar Patel was tried in absentia last year and convicted of a multi million-dollar Medicare fraud scheme. His office manager, Lorretta Tarango, was charged with copying fraudulent information provided to her onto claim forms and submitting them to the government. The feds say if read literally, the forms indicated Patel was seeing up to 100 patients a day for 30-second visits. Tarango was tried as a codefendant and found guilty of aiding and abetting the fraud. 

However, the district court ruled - and appeal court upheld - that Tarango deserved a new trial. Here's why:

"The crime of health care fraud is a specific-intent crime," the opinion reads. "Little evidence was presented to show that Tarango was aware that the medical diagnoses or the requests for medical equipment contained in the billing statements were false, and thereby could constitute illegal conduct on her part."

Dr. Patel, in contrast, based the improper billing on his medical expertise and knowledge of procedures, according to the decision.

Lesson Learned: An employee's intent to commit fraud - and knowledge of how to do it - may weigh heavily in a trial.