A licensed psychologist of Greenwich, Connecticut, waived his right to be indicted and pleaded guilty to healthcare fraud. According to court documents and statements made in court, the man is a licensed psychologist (Psychologist 1) who, along with another licensed psychologist (Psychologist 2), operated a practice out of his home office. The two psychologists were authorized providers for the Connecticut Medicaid program, Medicare, and other healthcare benefit programs. Psychologist 1 assumed responsibility for submitting claims for reimbursement for services allegedly provided by himself and by Psychologist 2, both at their home office and at various skilled nursing facilities within Connecticut.
In pleading guilty, Psychologist 1 admitted that he billed insurers for services that he knew were not rendered, including by billing for patients who were deceased, for dates of service when he was out of the country, for dates of service when Psychologist 2 was out of the country, and for dates of service when he was hospitalized. These fraudulent claims resulted in a loss of over $2,651,296, including a loss of $1,157,292 to the Connecticut Medicaid program and a loss of $119,092 Medicare.
Healthcare fraud carries a maximum term of imprisonment of 10 years. As part of his plea, Psychologist 1 has agreed to pay full restitution.
This was not Psychologist 1’s first offense. In 2002, he settled a federal lawsuit alleging healthcare fraud offenses, which was brought by the government in the Southern District of New York. Psychologist 1 agreed to pay $4 million in restitution and was excluded from participating in the Medicare program from April 2003 to November 2007. He was reinstated to the Medicare program in approximately December 2008.
Compliance Perspective
Issue
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. 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 for preventing and reporting false claims and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
