A federal jury convicted a Chicago-based doctor for his role in a more than $9.5 million healthcare fraud conspiracy, United States Attorney Henry C. Leventis for the Middle District of Tennessee announced on September 5, 2023. The defendant was indicted by a federal grand jury in December 2022. He was convicted of conspiracy to violate the federal Anti-Kickback Statute after a two-week trial.
According to the evidence at trial, the defendant, who was enrolled as a Medicare provider and licensed to practice medicine in multiple states, worked with purported telemedicine companies to obtain access to Medicare and Medicaid patients around the country. From March 2019 through September 2019, he and others caused the submission of more than $9.5 million in fraudulent claims to Medicare and Medicaid for cancer genetic tests. The defendant ordered thousands of these tests despite never actually meeting the patients in person or via telemedicine and never reviewing test results.
In exchange for providing signed orders for genetic testing, the defendant was paid kickbacks by co-conspirator telemedicine companies. These companies were, in turn, paid by co-conspirator marketing companies that targeted Medicare and Medicaid patients through door-to-door marketing, at senior fairs, at nursing homes, and at other locations, and convinced patients to provide their genetic material via a mouth swab kit.
The marketers then provided the swab kits to a lab in Tennessee for laboratory cancer genetic testing and in exchange for kickbacks paid to them by the lab. The lab billed Medicare and Medicaid for the tests.
Based on the count of conviction, the defendant faces up to 5 years in prison and a $250,000 fine. He will be sentenced on January 9, 2024. The jury was unable to reach a verdict on a second conspiracy charge.
Compliance Perspective
Issue
All laboratory tests performed for residents must be medically necessary in order to bill Medicare, Medicaid, or a private insurance company. When determining if a test or procedure is medically necessary, the results of the test should be needed to diagnose or treat an illness, injury, condition, or disease, or its symptoms. Claims for tests or procedures that are unnecessary in diagnosing or treating an illness, injury, condition, disease, or its symptoms may be seen as violations of the False Claims Act and may result in fines, criminal charges, and other sanctions.
Discussion Points
- Review your policies and procedures for laboratory testing services, including billing practices for laboratory testing, and for preventing and reporting false claims and anti-kickback statute violations. Update as needed.
- Train staff to ensure that ordered testing is medically necessary, and that if a laboratory test or other ordered service is considered medically unnecessary, the order should be clarified before proceeding. Include your medical director in this effort so he or she can intervene if a provider is not appropriately determining medical necessity for residents. Train all staff on the Anti-Kickback Statute and what can be considered a false claim or kickback. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that these trainings occurred and file each document in the employee’s individual education files.
- Periodically audit to ensure that laboratory tests meet the criteria for medical necessity. 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 unnecessary services are ordered, false claims are being submitted, or an illegal kickback has occurred.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
