A federal jury in Baltimore convicted a Maryland doctor on August 4, 2023, for submitting over $15 million in false and fraudulent claims to Medicare and a commercial insurer for patients who received COVID-19 tests at his testing sites.
According to court documents and evidence presented at trial, the defendant was an owner and the medical director of a practice which operated multiple drive-through COVID-19 testing sites in two Maryland counties. The defendant instructed his employees that, in addition to billing for COVID-19 tests, they were to bill for high-level evaluation and management visits. In reality, these visits were not provided to patients as represented. Rather, the defendant instructed his employees that the patients were “there for one reason only — to be tested,” that it was “simple and straightforward,” and that the providers were “not there to solve complex medical issues.”
The defendant ordered these high-level visits to be billed for all patients, including those who were asymptomatic, who were getting tested for COVID-19 for their employment requirements, and who were being tested for COVID-19 so that they could travel. The defendant caused the submission of millions of dollars in claims to Medicare and a commercial insurer for tens of thousands of high-level visits that were not provided as represented and were ineligible for reimbursement.
The jury convicted the defendant of five counts of healthcare fraud. He is scheduled to be sentenced on Nov. 7 and faces a maximum penalty of 10 years in prison on each count.
The defendant is the first doctor convicted at trial by the Justice Department for healthcare fraud in billing for office visits in connection with patients seeking COVID-19 tests. A federal district court judge will determine any sentence after considering the US Sentencing Guidelines and other statutory factors.
Compliance Perspective
Issue
Healthcare fraud affects everyone—individuals and businesses alike—and causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose individuals to unnecessary medical procedures, and increase taxes. 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. 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 policies and procedures for preventing and reporting false claims and suspicious billing practices. Update your policies and procedures as needed.
- Train all staff on what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically perform audits to ensure all 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. Perform Triple Checks for all Medicare Part A claims prior to submission to ensure that medical necessity is supported by appropriate documentation, and that services meet skilled care requirements.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
