A nurse practitioner who fraudulently billed commercial health insurers and Medicare nearly $4.4 million for services that he falsely claimed to have provided to patients in Rhode Island, New York, and Florida, pleaded guilty in federal court in Rhode Island to an eleven-count information charging him with healthcare fraud, mail fraud, aggravated identity theft, and causing the introduction of misbranded drugs into interstate commerce.
The nurse practitioner admitted that he routinely submitted fraudulent claims for in-person patient services that he falsely claimed to have performed at his offices in Rhode Island, New York, and Florida. In some instances, the patients that he claimed he met with in person were out of the country at the time of the alleged visits. On many other occasions that he claimed to have been seeing patients, he was either in a different state or another country, often times in Russia. The investigation also determined that the supposed office that he maintained in Rhode Island, and to which he had some payments mailed, was a nonexistent medical practice at which no medical services were provided.
Additionally, the nurse practitioner admitted to a federal judge that he waived copayments for some Medicare patients, despite being aware that waiving copayments is prohibited. By waiving copayments that patients otherwise would be responsible for, he induced his patients not to report his fraudulent billing to Medicare. He also admitted that he carried out schemes in which he would use patient names and information to get prescriptions to be filled at pharmacies. He arranged for those prescriptions to be returned to him so that he could then distribute those drugs to individuals other than those in whose names the prescriptions were filled.
According to a signed plea agreement filed with the court, in addition to pleading guilty to charges of healthcare fraud, mail fraud, aggravated identity theft, and causing the introduction of misbranded drugs into interstate commerce, the nurse practitioner will forfeit $4,379,158.98, the sum of money equal to the amount he received from perpetrating healthcare fraud.
Compliance Perspective
Issue
Ordering and billing for medications, tests, procedures, and durable medical equipment 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. 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. 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 on determining if services for patients are necessary. Also review policies and procedures for preventing and reporting false claims.
- Train appropriate staff on how to determine each resident’s level of care and if services provided are reasonable and necessary. Include information on how to report concerns and suspected violations, and make sure staff know that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit to ensure that medical tests, procedures, and prescriptions meet the criteria for medical necessity and that they’ve been approved by the resident’s primary physician. 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. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
