A Connecticut doctor was sentenced on May 9, 2024, for receiving kickbacks in exchange for ordering medically unnecessary brain scans. He was sentenced to one year and one day in prison, to be followed by one year of supervised release. He was also ordered to pay $1.34 million in restitution to Medicare, Medicaid, and private insurers. In July 2022, the defendant pleaded guilty to one count of conspiracy to commit healthcare fraud and one count of conspiracy to receive kickbacks.
The defendant, a licensed medical doctor in Connecticut for nearly 40 years, owned and operated an ophthalmology practice. From 2014 through 2019, he conspired with a principal for a medical diagnostics company that performed transcranial doppler (TCD) scans — brain scans that measure blood flow in parts of the brain — to order hundreds of medically unnecessary TCD scans in exchange for kickbacks. He and his co-conspirator used false patient diagnoses to order the unnecessary brain scans, for which the co-conspirator would submit claims to Medicare and other insurance companies on behalf of the medical diagnostic company for payment.
In exchange, the defendant was paid cash kickbacks of $100 to $125 per test that he ordered, as well as sham administrative services fees. The scheme resulted in fraudulent bills of over $3 million to Medicare and private insurance companies.
Compliance Perspective
Issue
All members of the healthcare team should be knowledgeable of what may be considered an illegal kickback. A kickback, or failure to report a kickback, can result in fines and other sanctions, including placement on the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE). Staff should also understand their responsibility to identify and report concerns of utilization of any services that they believe are unnecessary or inappropriate for a resident, to include ordered tests, procedures, treatments, therapies, and medications. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures on ensuring that all provided resident services are reasonable and necessary and for prevention of false claims. Also review your policies and procedures for preventing and reporting kickbacks. Update your policies and procedures as needed.
- Train appropriate staff on how to determine if services each resident is receiving are reasonable and necessary. Train all staff on the Anti-Kickback Statute and what can be considered a kickback. Ensure appropriate staff monitor for potential false claims related to unnecessary or inappropriate services that are unsupported by documentation. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit medical records to ensure that all services provided to residents are reasonable and necessary. Also periodically audit to ensure that staff are aware of what should be done if they suspect unnecessary services are being ordered or provided and if an illegal kickback has occurred, whether intentionally or unintentionally.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
