Practice Management Alert

The list of healthcare fraud offenders prosecuted keeps growing.

The U.S. Department of Justice (DOJ) is going after physicians and other individuals committing fraud and putting them in prison. Learn from their mistakes and misdeeds.

Tennessee Chiropractor, NP Fined for False Claims Act Allegations

The chiropractor, through his management company, managed four pain clinics in Tennessee that submitted payment requests to Medicare and TennCare for painkillers, including opioids. These prescriptions had no legitimate medical purpose, according to U.S. Attorney Don Cochran of the Middle District of Tennessee.

The chiropractor and management company paid more than $1.45 million, plus interest, and the nurse practitioner (NP) must pay $32,000 and surrender her Drug Enforcement Administration (DEA) registration until October 2021, the DOJ says in a press release.

The DOJ press release quotes U.S. Department of Health and Human Services Office of Inspector General Special Agent Derrick L. Jackson on the ground in Tennessee, illustrating some of the reasons for the Feds' tenacity: "The opioid epidemic has had a crushing effect on patients and families across middle Tennessee. Pill mills like these billed medically unnecessary services to Medicare and TennCare and contributed to problems of opioid abuse and addiction."

The case was brought to the attention of the United States and Tennessee after a former office manager filed a qui tam (whistleblower) lawsuit against the chiropractor, NP, and management company.

Michigan Doctor Sentenced to Prison for Fraud

A Detroit-area doctor was recently sentenced to 24 months in prison for "his role in a $1.7 million healthcare fraud scheme that involved billing Medicare for physician home visits that were medically unnecessary and/or were billed under unwarranted treatment codes that resulted in inappropriately high payments," according to a DOJ press release.

Specifically, the doctor was part of a home-visiting physician company that saw homebound Medicare patients in their homes. The Medicare Fraud Strike Force discovered that these patient visits did not qualify for payment because "the patients either were not sick or were not homebound," the DOJ says.

The physician "conspired with others to bill Medicare for the highest paying codes for these visits, even though the visits were short and perfunctory, or were unnecessary, the evidence showed," the DOJ says. He also "referred these patients for home health services that were unnecessary and were then billed to Medicare."

New Jersey Physician to be Sentenced for Illegal Opioid Scripts

"A Long Valley, New Jersey, man admitted to writing illegal prescriptions for oxycodone and conspiring to bill Medicare and Medicaid for certain allergy tests without performing the required patient examinations," according to a DOJ press release.

The urology specialist was charged with one count of illegally distributing oxycodone and one charge of conspiracy to commit healthcare fraud, the DOJ says.

The doctor sold prescriptions to a person acting under law enforcement's instructions without previously performing a patient examination or medical treatment, the DOJ says. Additionally, the doctor and his clinic "conspired to submit phony bills to Medicare and Medicaid for certain allergy tests that ... prescribed without examining the patients to determine if the tests were medically necessary. As a result, [the physician] and the other conspirators were able to fraudulently obtain at least $30,000 from Medicare and Medicaid," the DOJ says.

The Feds are serious about opioid charges, and the penalties are steep. "The unlawful distribution of oxycodone charge carries a maximum potential penalty of 20 years in prison and a $1 million fine, or twice the gross gain or loss from the offense," the DOJ says. "The healthcare fraud conspiracy charge carries a maximum potential penalty of 10 years in prison and a $250,000 fine."

California Urologists Prosecuted under Stark Law

Two California urologists agreed to pay $1.085 million in response to the allegations. The fine is to "resolve allegations that they submitted and caused the submission of false claims to Medicare for image guided radiation therapy (IGRT) that was referred and billed in violation of the physician self-referral law (commonly known as the 'Stark Law') and the Anti-Kickback Statute, the Department of Justice announced," the DOJ says in a press release.

The U.S. Attorney's Office alleged that the two physicians knowingly caused eight other urologists to violate the Anti-Kickback Statue, as well as enter into lease agreements where they could bill for referrals for image-guided radiation therapy (IGRT), the DOJ says.

The DOJ announced that the two physicians "violated the Stark Law by improperly billing Medicare for their own IGRT referrals" at their own facility. The two physicians had separate companies and entities, but their financial arrangements didn't comply with Stark Law exceptions, the DOJ says.

"The Anti-Kickback Statute and the Stark Law are intended to ensure that a physician's medical judgment is not compromised by improper financial incentives," the DOJ says. "The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by federal health care programs, including Medicare. The Stark Law forbids healthcare providers from billing Medicare for certain services referred by physicians who have a financial relationship with the entity performing the service, unless an exception applies."

Resource: Keep up to date with Criminal and Civil Enforcement pertaining to health care, here: https://oig.hhs.gov/fraud/enforcement/criminal/.