Healthcare Compliance Perspective – Healthcare Fraud:
Knowingly making false statements and claims to an insurance company, state or federal benefit program in order to be reimbursed for services never performed or provided may result in indictments and convictions for violating the False Claims Act. Such convictions may result in imprisonment and/or fines, and the likely loss of licensure. Healthcare providers must ensure that when leaving a private practice, that their unique provider numbers are no longer used for submitting claims.
Healthcare fraud and making false statements in connection with a scheme to defraud insurance companies administering healthcare benefit programs were the basis for the December convictions the jury gave to two doctors in California late last year. The two doctors were married and shared a practice together.
The orthopedic surgeon was sentenced early in April to serve 12 months plus one day in prison followed by a 3-year term of supervised release. He will begin serving the sentence June 6, 2018. His wife, the family practitioner, had her sentencing postponed.
While both doctors were acquitted of charges involving conspiracy and money laundering and some other charges, one of the doctors (an orthopedic surgeon and former U.S. Navy captain) was also acquitted on five other counts. His wife (a family practitioner) was found guilty of five counts of healthcare fraud and five counts of making false statements on the claims submitted to some healthcare benefit programs. The surgeon was found guilty of one count of making a false claim statement.
The period during the indictments of the two covered was almost six years long from 2009 through September 2014.
The evidence presented at the trial indicated that the family practitioner knew that the claims she submitted to the multiple benefit programs were not eligible for payment. These claims included patients she had not seen. She also submitted claims for patients seen by a physician no longer associated with her practice by apparently using that physician’s unique identifier number.
The orthopedic physician also was shown by trial evidence to have submitted at least one false claim related to his physical therapy practice.
