Compliance Perspective – Healthcare Fraud:
The Compliance Officer together with the Administrator and the Compliance Committee will verify that appropriate policies on the interactions with other healthcare industry stakeholders (i.e., hospitals/physicians, pharmaceutical/device representative, vendors, etc.) are in place. Administrative Staff will be trained regarding the appropriate inclusion of compliance obligations in the executed contractual agreements and the due diligence to be conducted periodically on third parties to ensure that corrective action is taken based on background/sanction screening. An audit will be conducted periodically to ensure that any third parties associated with the facility are compliant and have not been excluded for any fraudulent or criminal activities based on background/sanction screening.
The founder and chief executive officer of a nonprofit public benefit corporation that provided health and dental services in northern California recently pleaded guilty to healthcare fraud and conspiracy to receive kickbacks. The 57-year-old woman was also a licensed nurse practitioner.
According to court documents, between January 1, 2014, and March 2017, the woman orchestrated a s
cheme to bill Medicare and Medi-Cal for services she knew were not reimbursable, and she profited by over $3.7 million from her fraud. For example, she billed Medi-Cal for health and dental services that were not rendered and for unnecessary healthcare services. She also billed Medi-Cal for office visits with purportedly licensed doctors when the patients were dispensed Suboxone, an opioid medication, in the parking lots of McDonald’s and Rite Aid in baggies.
According to the plea agreement, the woman also received thousands of dollars in kickbacks in cash from an account executive for a laboratory in exchange for using the laboratory to perform her nonprofit facility’s patient testing.
The woman is scheduled to be sentenced in a U.S. District Court on January 28, 2019. She faces a maximum statutory penalty of 20 years in prison and a fine of twice the value of her gain of $3.7 million. The actual sentence will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guideline, which consider several variables.
