A physician pleaded guilty in federal court to his role in a conspiracy to make false statements that resulted in more than $1.4 million in Medicare and Medicaid fraud, according to a press release from the US Attorney’s Office, Western District of Missouri, on February 2, 2024.
The physician, who practiced medicine in Missouri, entered into a contract with a company identified in court documents as “Company A.” The physician provided alleged telemedicine consultation services to Company A’s clients and was paid $30 per consultation. He utilized electronic portals to receive information about the patients, as well as to sign patient forms, orders, and letters of medical necessity in which he certified that genetic tests were medically necessary.
The physician admitted that he had a doctor-patient relationship with very few, if any, of the Medicare or Medicaid beneficiaries for whom he ordered genetic testing and also that he provided no follow-up care for these patients. He signed pre-printed patient forms that certified the genetic tests were “medically necessary” and that the “results will determine the patient’s medical management and treatment decision.” He knew those statements were false and fraudulent because he knew that he would not receive the reports or use them to treat patients.
The orders were submitted to laboratories, many of which, unbeknownst to him, paid illegal kickbacks to the individuals and entities who conspired to submit false claims to Medicare and Medicaid.
The physician admitted that he signed orders for genetic testing for Medicare beneficiaries that caused Medicare to pay approximately $1,030,906 to the laboratories that billed for those genetic tests from March 2017 to September 2019. He also admitted that he signed orders for genetic testing for Medicaid beneficiaries that caused Medicaid to pay approximately $376,981 from November 2018 to October 2019.
Under the terms of his plea agreement, the physician must pay $140,788 in restitution (or in such other amount as determined by the court) to the government. Under federal statutes, he is subject to a sentence of up to five years in federal prison without parole. A sentencing hearing will be scheduled after the completion of a presentence investigation by the United States Probation Office.
Compliance Perspective
Issue
In recent years, the Office of Inspector General (OIG) has conducted dozens of investigations of fraud schemes involving companies and individuals that purported to provide telehealth, telemedicine, or telemarketing services and exploited the growing acceptance and use of telehealth. These schemes raise fraud concerns because of the potential for considerable harm to federal healthcare programs and their beneficiaries, which may include: (1) an inappropriate increase in costs to federal healthcare programs for medically unnecessary items and services and, in some instances, items and services a beneficiary never receives; (2) potential to harm beneficiaries by, for example, providing medically unnecessary care, items that could harm a patient, or improperly delaying needed care; and (3) corruption of medical decision-making. Practitioner arrangements with telemedicine companies may also lead to criminal, civil, or administrative liability under federal laws including, for example, the federal anti-kickback statute, OIG’s exclusion authority related to kickbacks, the Civil Monetary Penalties Law provision for kickbacks, the criminal healthcare fraud statute, and the False Claims Act.
Discussion Points
- Review policies and procedures regarding the use of telemedicine within the facility and preventing fraud, waste, and abuse. Also review your policies and procedures for operating an effective compliance and ethics program to ensure that the identifying and reporting of false claims or kickbacks is part of your policy.
- Provide education to nursing and business office personnel on their responsibility to identify and report any concerns that unnecessary medications, treatments, supplies, or equipment are being ordered for residents. Train staff about fraud, waste, and abuse and the prohibition regarding acceptance of illegal kickbacks and bribes in exchange for ordering medical equipment, performing lab tests, prescribing medications, and other activities. Staff who observe or reasonably suspect that kickbacks and bribes are being offered or accepted should report such suspicions to their supervisor or through the facility’s Hotline.
- Periodically audit to determine if telemedicine tools are being used appropriately and that facility personnel are not being offered or accepting bribes or kickbacks. Also audit to ensure that staff are aware of their responsibility to identify compliance and ethics concerns and to promptly report violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
