If a resident, their family member, or responsible party/bill payer sees discrepancies in statements from insurance companies, they should check with the doctor’s office. If they are not satisfied with the response they receive,they should notify the carrier, as well as any appropriate regulatory agencies.
Risk Management Perspective
Policy/Procedure: A goal is to establish transparency in whatever the process is so the healthcare provider and their trusted compliance and ethics team are able to see what is going on, so even if they are a half step behind they will able to mitigate the damage and make sure it does not happen again.
Training: Compliance and ethics code of conduct must be continuously presented to employees, independent contractors, temporary staff, vendors, and all other participants in the total delivery of care.
Audit: Policies and procedures need to promote transparency so that auditing can be effective. Periodically assess the policies and procedures and their implementation to ensure they are comprehensive, complete, and current. Auditing needs to reflect multiple sources of oversight.
A seemingly successful orthopedic surgeon, who saw dozens of patients a day and brought in millions of dollars in fees for his suburban New York medical group,was inflating charges and billing for surgeries he didn’t perform. The years-long fraud culminated in a guilty plea on a single count in federal court in 2013 which ended his surgical practice. According to federal prosecutors,while he was waiting to be sentenced, he had begun a new criminal scheme that would go undetected for years until he was arrested again in April. Over the past five months, thousands of patients received notices from several insurance companies that he had posed as another doctor in order to review their medical records in coverage disputes. At least 2,500 people nationwide were affected,according to data compiled by Bloomberg, but the full reach of the alleged fraud has not been made public. In the latest criminal case, prosecutors say the surgeon defrauded six review companies for $876,000, using a fake Google email address, a shell company registered in the name of a family member to a Brooklyn address, and the credentials of another physician.
