A Georgia man was sentenced on August 18, 2023, to 27 years in prison for his role in a scheme to defraud Medicare by submitting over $463 million in genetic and other laboratory tests that patients did not need, and that were procured through the payment of kickbacks and bribes.
According to court documents, the defendant owned a lab enrolled with Medicare that performed sophisticated genetic tests. He conspired with patient brokers, telemedicine companies, and call centers to target Medicare beneficiaries with telemarketing calls falsely stating that Medicare covered expensive cancer genetic tests. After the Medicare beneficiaries agreed to take a test, the defendant paid kickbacks and bribes to patient brokers to obtain signed doctors’ orders authorizing the tests from telemedicine companies.
To conceal the kickbacks and bribes, the defendant required patient brokers to sign sham contracts that falsely stated that the brokers were performing legitimate advertising services for the lab, when, as he well knew, the brokers were deceptively marketing to Medicare beneficiaries and paying kickbacks and bribes to telemedicine companies for genetic testing prescriptions.
The defendant knew that the telemedicine doctors robo-signed prescriptions for expensive genetic testing even though they were not treating the beneficiaries, often did not even speak with them, and made no evaluation of medical necessity. From July 2016 through August 2019, his lab submitted more than $463 million in claims to Medicare, including for thousands of medically unnecessary genetic tests, of which Medicare paid over $187 million. In that time frame, the defendant personally received over $21 million from Medicare in connection with the fraud.
Acting Assistant Attorney General Nicole M. Argentieri of the Justice Department’s Criminal Division said it was one of the largest genetic testing fraud cases ever tried to verdict.
The FBI and HHS-OIG investigated the case.
Compliance Perspective
Issue
Ordering and billing for services a resident does not receive or that are not medically necessary can be seen as fraudulent billing or submission of false claims. It is illegal to submit claims for payment to Medicare, Medicaid, and private insurance that you know or should know are false or fraudulent. Healthcare fraud can be committed by medical providers, company owners, patients, and others who intentionally deceive the healthcare system to receive unlawful benefits or payments. All staff who provide skilled services must understand what constitutes reasonable and necessary skilled services. The skilled services must be based upon a patient’s ability, need, and what is reasonable for the patient. Failure to promptly report suspected fraud can result in citations, fines, and other sanctions.
Discussion Points
- Review your policies and procedures regarding the ordering of laboratory tests and x-rays, durable medical equipment, and the use of telemedicine within the facility, and for determining if services for residents are necessary. Also review policies and procedures for identifying and preventing illegal kickbacks and reporting false claims.
- Train appropriate staff on how to determine each resident’s level of care and if services ordered and/or provided are reasonable and necessary. Also train all staff on federal and state anti-kickback statutes and what can be considered an illegal kickback. Staff who observe or reasonably suspect that unnecessary testing or services are being ordered or provided and 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 unnecessary services are being ordered or if billing has occurred for services not provided. Determine if telemedicine tools are being used appropriately and ensure that facility personnel are not being offered or accepting bribes or kickbacks. Also periodically audit to ensure that documentation demonstrates medical necessity for all claims being submitted and that services have been approved by the resident’s primary physician or appropriate designee. Survey professional staff on their knowledge of what can be considered medical necessity. Also periodically audit staff understanding to ensure that they are aware of what should be done if they suspect a false claim 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.*
