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Medicare Compliance & Reimbursement

Fraud & Abuse:

Feds Focus on Physicians in March Enforcement

Published on Tue Mar 22, 2022

Warning: Several settlements include million-dollar fines — and prison time.

If you thought the feds were going to give physicians a break as worries about the pandemic wane, you’d be sorely mistaken. As enforcement activity ramps up, the following cases highlight the feds’ heightened scrutiny of Medicare fraud committed by physicians — and their willingness to bring significant penalties.

Take a look at these high-profile March 2022 charges and settlements aimed at physicians.

In New York: If you think upcoding is no big deal, think again. On March 3, Rye, New York-based ophthalmologist Ameet Goyal must “pay forfeiture of $3.6 million and restitution of $3.6 million” as well as spend eight years in jail for a seven-year upcoding scheme to dupe Medicare out of millions, a Department of Justice (DOJ) release suggests. Goyal billed “simpler, lower-paying surgical procedures and examinations as complex, higher-paying major operations in fraudulent billings submitted to Medicare, private insurance companies, and patients,” the DOJ says.

But that’s not all. He falsified medical records, threatened his staff to lie and forced them to commit fraud to keep their jobs, charged patients thousands for services and items never rendered — and used his own personal information to apply for not one but two CARES Act loans through the SBA Paycheck Protection Program (PPP).

In New Jersey: One case in Fort Lee underscores why you shouldn’t bill Medicare for allergy services that your patients don’t need. On March 8, Alice Chu, a Clifton, New Jersey-based rheumatologist, was convicted of “bill[ing] Medicare and other health insurance programs for expensive infusion medication that her practice never purchased,” and she “also fraudulently billed millions of dollars for allergy services that patients never needed or received,” a DOJ release mentions.

Chu will be sentenced in July and could get upwards of 10 years in prison.

In California: Hospice fraud is on the rise — and the feds are on top of it. Physician Victor Contreras in Santa Paula was in cahoots with Lancaster-based patient recruiter, Callie Jean Black, to defraud Medicare by way of a hospice services scam that went down from 2015 to 2019. They “bilked Medicare out of more than $30 million for medically unnecessary hospice services provided to patients who were obtained through illegal kickbacks,” a DOJ report notes.

Both were arrested on March 8; however, Contreras had already been in hot water with the feds. He was on probation for previously certifying unnecessary hospice services.

Another co-defendant, Juanita Antenor, who owned Arcadia Hospice Provider Inc. and operated Saint Mariam Hospice Inc. where the fraudulent claims were filed, is on the run and believed to be hiding out in the Philippines, according to the Justice Department.

In Michigan and Ohio: This massive two-state case highlights the continued focus the HHS Office of Inspector General (OIG) and DOJ have on opioid prescribing and billing. On March 9, 16 defendants, including 12 physicians, were sentenced to prison for a $250 million opioid scheme that benefited from the suffering of addicts with more than 6.6 million doses of medically unnecessary opioids being distributed, a DOJ release says.

“The scheme involved doctors refusing to provide patients with opioids unless they agreed to unnecessary back injections,” the release notes. “Perpetrated through a multi-state network of pain clinics from 2007 to 2018, the evidence established that the clinics were pill mills frequented by patients suffering from addiction, as well as drug dealers, who sought to obtain high-dosage prescription drugs like oxycodone.” Court documents also showed that the injections caused more pain for many of the patients and long-term issues that indicated the cycle of abuse.

“It is unconscionable that doctors and health care professionals would violate their oath to do no harm and exploit vulnerable patients struggling with addiction,” cautions Kenneth A. Polite Jr., assistant attorney general of DOJ’s Criminal Division. “These are not just crimes of greed, these are crimes that make this country’s opioid crisis even worse — and that is why the department will continue to relentlessly pursue these cases.”

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