Iowa Doctor Pleads Guilty to Submitting False Claims to Medicare and Medicaid
A private practice physician, who also worked in Iowa as a County Coroner and the Medical Director for multiple nursing homes, recently pleaded guilty and was convicted on one count of making false statements related to healthcare matters. The doctor’s assertion of guilt was part of a plea agreement with the U.S. Attorney for the Northern District of Iowa conducting a civil investigation regarding alleged “upcoding” of claims submitted to Medicare and Medicaid.
The investigation indicated that the doctor falsely billed more than 93% of his visits to nursing home residents under a higher reimbursement rate than the visits warranted.
After a Medicare contractor notified the doctor that his claims for 2017 and 2018 were significantly more expensive than other doctors, he submitted sworn written answers falsely detailing the time spent for claims at two nursing homes. In truth, a federal agent conducted in-person surveillance of the doctor that showed he spent a total of 47 minutes at one facility and did not visit the other facility at all on the date when he claimed he had spent about 35 minutes with each of 12 residents at two nursing homes. The administrator of the first nursing home estimated that the doctor spent about five minutes per resident whenever he visited the facility.
In further false statements about claims billed for services provided to nine residents, videotaped surveillance showed the doctor was only at the facility for a total of 14 minutes.
Altogether, the doctor admitted to submitting 1,140 unjustified false claims from January 2014 through November 2018 to Medicare and received $107,980.59. He also admitted receiving and another $9,218.73 from Medicaid for other unjustified claims. Along with repaying those amounts, the doctor faces a possible maximum sentence of five years in prison, a $250,000 fine and three years of supervised release.
Compliance Perspective
Failing to oversee that the time and frequency of visits by physicians and the Medical Director are appropriate in providing care residents need and reasonable for submission of claims to Medicare and Medicaid may be considered fraud and a violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding the responsibilities of the Medical Director and tracking, to some degree, the time and frequency of visits spent by both the Medical Director and physicians providing care of the residents.
- Train staff to be alert and report, either to a supervisor or through the Hotline, situations that might indicate that a Medical Director or any physician is just “going through the motions” of providing care, and which might point to the potential for submitting false claims to Medicare and Medicaid.
- Periodically audit, to the extent feasible, the length and frequency of visits by physicians and the Medical Director to ensure residents receive adequate medical management.
