On December 2, 2021, a Mississippi man was sentenced by a federal judge to 78 months in prison for healthcare fraud and conspiracy. In August 2021, the man pled guilty to four counts of healthcare fraud and one count of conspiracy to commit healthcare fraud.
Documents initially filed on October 17, 2016, by the government stated that the Mississippi man signed a written agreement in which he agreed to be excluded from the Medicare Program for 10 years. The exclusion agreement provided that Medicare would not pay claims submitted by anyone who employed the Mississippi man in a management or administrative role. Records show that from 2016 until 2021, the Mississippi man committed healthcare fraud by continuing to manage and control pharmacies that submitted claims for payment to Medicare. The man tried to avoid detection by ensuring those who submitted Medicare enrollment/revalidation paperwork for these pharmacies would not disclose his ownership interest or managerial role in these pharmacies.
Medicare paid approximately $16,109,446.67 to the pharmacies in which the man had an ownership interest or managerial role from October 17, 2016, through August 16, 2021. The court also ordered the man to forfeit $7.1 million and to repay more than $16.1 million in restitution.
Special Agent in Charge Derrick L. Jackson of the HHS-OIG Atlanta Regional Office stated, “Being a healthcare professional in the Medicare program is a privilege, not a right. When an excluded healthcare provider knowingly disregards restrictions and bills federal healthcare programs, they divert funds intended to provide care and services for our country’s most vulnerable population. Today’s sentencing should serve as a warning to those who seek to enrich themselves through such fraud schemes.”
Compliance Perspective
Issue
All employees, vendors, and contractors must be checked prior to employment or contracting to ensure that they do not appear on the Office of Inspector General’s List of Excluded Individuals and Entities (LEIE) at https://exclusions.oig.hhs.gov or the List of Debarred Contractors at https://www.sam.gov. It is essential that the databases are routinely monitored to ensure that no current employee, vendor, or contractor has recently become excluded. The results of the exclusion list audits should be discussed in the facility’s compliance and ethics committee meetings, with any concerns immediately addressed upon discovery.
Discussion Points
- Review your policies and procedures on routinely monitoring the exclusion lists. Update your policy as needed.
- Train appropriate staff on your policy and procedures for monitoring the OIG’s List of Excluded Individuals and Entities and the list of Debarred Contractors and the required response if concerns are identified. Document that the trainings occurred and file each signed document in the employee’s individual education file.
- Periodically audit to ensure that all employees, vendors, and contractors have been checked against the exclusion list website and that repeat monitoring is ongoing.
FOR MORE INFORMATION ON THIS TOPIC VIEW: STAYING ON TOP OF EMPLOYEE CHECKS.
