A doctor who ran a family clinic in Oklahoma and also took care of nursing home residents, was sentenced to serve 54 months in federal prison for illegal drug distribution and healthcare fraud. The doctor was charged with numerous counts of drug distribution—specifically, dispensing opioids and other drugs outside the usual course of professional practice and not for a legitimate medical purpose—along with multiple counts of Medicare/Medicaid fraud based on, among other things, services he billed for while out of the country and services he billed for related to care of residents in nursing homes without performing the services or supervising those who provided them.
During the pendency of the doctor’s prosecution on these drug and healthcare fraud charges, he was also charged in the Southern District of Florida with one count of conspiracy to pay healthcare kickbacks.
The doctor admitted to fraudulently billing Medicare at a higher rate for services that were performed by a nurse practitioner instead of himself. He also pleaded guilty in his Florida case. He was sentenced to serve a 54-month sentence on his two Oklahoma-based charges, and another 24 months on his Florida case, to be run concurrent to his Oklahoma sentences. He was also ordered to pay a fine of $13,362.00, to pay restitution of $112,384.61 to the Centers of Medicare & Medicaid Services, and to forfeit $202,597.18. In imposing the sentence, the judge specifically noted the detriment to the community in that the number of prescriptions from controlled substances far exceeded the population of the city in Oklahoma where the doctor practiced medicine.
“Medical doctors take an oath to help those in times of need,” said US Attorney Robert J. Troester. “Dr. Robison prescribed addictive, dangerous, and powerful controlled substances without a legitimate medical purpose and abused the medical system to line his pockets for financial gain. This conduct violated his oath and federal law. My office remains committed to working with our law enforcement partners to hold accountable doctors who fuel the opioid crisis and exploit their oath for money.”
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.*
