A Pennsylvania physician recently pleaded guilty in a U.S. District Court to one count of healthcare fraud, one count of importation contrary to law, and two counts of distribution of controlled substances. The physician, who is a rheumatologist, participated in a scheme to illegally import medications not approved by the U.S. Food and Drug Administration (FDA), administer these medications to his patients, and unlawfully distribute oxycodone.
One of the special agents in charge of the investigation pointed out that non-FDA approved medications are not reimbursed by Medicare due to the risk they may pose to patients.
The physician falsely billed federal healthcare benefit programs, e.g., Medicare and Medicaid, for approximately $2.3 million and was paid directly approximately $1.1 million, pocketing the profits for himself. In his guilty plea, he admitted to illegally importing non-FDA–approved biologic medications from about January 2014 through March 2018. The illegally obtained drugs included Remicade, Synvisc, Synvisc-One, Orencia, Prolia/Xgeva and Boniva.
Another agent noted that the physician knowingly prescribed oxycodone to patients who were abusing illicit street drugs such as cocaine and heroin. The physician also knew from reviewing the urine tests of these patients that they were not actually taking the drugs he prescribed for themselves.
Compliance Perspective
Failure by a facility to ensure that physicians treating residents have not been excluded as Medicare and Medicaid providers may be considered a violation of state and federal regulations and cause the facility to be excluded as a Medicare and Medicaid healthcare provider.
Discussion Points
- Review policies and procedures regarding the need to perform background checks on new and existing physicians providing healthcare services to the residents of the facility.
- Train staff responsible for performing background checks on how to use the government’s LEIE links to screen every employee, contractor, and vendor against the OIG List of Excluded Individuals and Entities and check all employees, contractors, and vendors against the OIG list of debarred contractors.
- Periodically audit to determine if the facility is performing background checks of physicians and other providers on an ongoing basis.
