A former Montana nurse practitioner admitted on August 1, 2024, to prescribing controlled substances despite having a suspended license. She also admitted to falsely billing an insurance company almost $62 million for vitamin B-12 injections in which she received nearly $600,000 for the false claims.
The defendant pleaded guilty to healthcare fraud and to use of a registration number issued to another person. She faces a maximum of 10 years in prison, a $250,000 fine, and three years of supervised release on the healthcare fraud charge and a maximum of four years in prison, a $250,000 fine, and one year of supervised release on the charge of using the registration of another person.
The government alleged in court documents that the defendant was a nurse practitioner whose license was suspended by the Montana Board of Nursing on April 1, 2022. The defendant continued to prescribe controlled substances using her own name and Drug Enforcement Administration (DEA) registration number until June 8, 2022. The DEA contacted the defendant through her attorney, and she agreed to voluntarily surrender her DEA registration. However, she continued to prescribe controlled substances using the name and DEA registration number of a friend who was also a nurse practitioner.
The defendant misrepresented to her friend that her nursing license was on probation, not suspended, and that she would not use her friend’s information to prescribe drugs. In fact, the defendant used her friend’s name and DEA registration number for at least 12 prescriptions of controlled substances.
The government further alleged that the defendant billed Blue Cross Blue Shield of Montana for vitamin B-12 injections that did not occur. In August 2021, she started falsely increasing the number of units of a standard vitamin B-12 injection from one unit to 1,000 units. This increased the corresponding payment from the insurance company for each injection from roughly $4.88 to $4,880.
After her license was suspended, the defendant started submitting numerous such claims each month to Blue Cross Blue Shield of Montana by backdating claims to before her license was suspended. This conduct continued through May 2022, when she submitted four claims, this time claiming $15 million per vitamin B-12 injection to a new patient. The defendant never gave that patient any vitamin injections, and Blue Cross Blue Shield of Montana did not pay those claims. In total, the defendant billed the insurance company at least $61,995,000 for false vitamin B-12 injections and received at least $593,583 from those false claims.
Compliance Perspective
Issue
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. 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. In addition, staff should be knowledgeable in how to report suspicious billing practices. Professional licenses should be verified upon hire, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) should be checked monthly to ensure no current employees are on the list. Professional license active status should also be tracked regularly. Anyone who hires or partners with an individual or entity on the LEIE may be subject to civil monetary penalties (CMP).
Discussion Points
- Review policies and procedures for verifying the status of professional licenses, including confirming that they are not included on a state or OIG exclusion list. Also review policies and procedures for preventing and reporting false claims and suspicious billing practices.
- Train appropriate staff to follow protocols for verification of licenses and certifications of employees at the time of hire and on an ongoing basis to ensure that those licenses remain up to date and are unencumbered. Ensure that training is provided to licensed personnel about their responsibility to maintain an active license and to notify administration should their license be suspended, expire, or if they are added to the OIG’s LEIE or a state exclusion list. Also train staff on what can be considered a false claim. Include information on how to report concerns and suspected violations.
- Periodically audit to verify that the licensing and certifications of employees are valid and up to date and that OIG LEIE checks are routinely conducted. Immediately address any negative findings. Also periodically perform audits to ensure all staff are aware of the importance of identifying compliance and ethics concerns and their responsibility to report them to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
