A suburban Chicago doctor was sentenced to six months in federal prison and ordered to pay a $1 million fine for submitting fraudulent claims to Medicare and a private insurer, according to a June 16, 2023, press release from the US Attorney’s Office for the Northern District of Illinois.
The doctor owned a cancer therapy practice. From 2015 to 2021, he caused fraudulent claims to be submitted to Medicare and Blue Cross Blue Shield (BCBS) of Illinois falsely stating that mole-removal procedures had been provided to patients on multiple dates. However, the services were not provided as billed. The doctor had removed multiple moles on a single date, but the procedures were billed as though they were removed on separate dates to maximize reimbursement from Medicare and BCBS. The doctor admitted that he knew insurers paid more for moles removed on separate dates than multiple moles on a single date. Medicare and Blue Cross Blue Shield ultimately paid him approximately $1.7 million as a result of his scheme.
To conceal his fraudulent conduct, the doctor stored moles onsite at his office and delayed sending them for pathology testing. As a result, the pathology reports made it appear as though he had removed the moles on separate dates. His conduct delayed critical testing on moles that he removed for serious illnesses, including cancer. The doctor also created fake patient charts, including pre-operative and post-operative notes that indicated he performed mole-removal procedures on dates when he was not in Illinois. Medicare conducted an audit of his patient charts, so he instructed his staff to create false records to hide the fact that he had committed healthcare fraud.
Compliance Perspective
Issue
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. The Office of Inspector General (OIG) strongly encourages nursing facilities to have comprehensive procedures in place to ensure that services are of an appropriate quality and level and are in fact delivered to nursing facility residents as ordered and as reported in claims for reimbursement. Moreover, accurate documentation at the time of service is critical to ensuring that billing is fully supported. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected. Monitor to ensure that quality care is provided for all residents, with any identified concerns addressed immediately. Facilities may wish to engage in resident and staff interviews; medical record reviews; consultations with attending physicians, the medical director, and consultant pharmacist; and personal observations of care delivery as part of their auditing and monitoring efforts.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
