Jury Finds Texas Doctor Guilty of $16 Million Fraud Scheme
After a trial lasting six days, a Texas physician was found guilty of committing one count of conspiracy to commit healthcare fraud, one count of conspiracy to solicit and receive healthcare kickbacks, and two counts of false statements relating to healthcare matters.
Evidence presented during the trial showed that from January 2012 to August 2016, the doctor along with others, conspired to defraud Medicare by signing false and fraudulent plans of care and other medical documents, and submitting fraudulent claims to Medicare to make it appear that the doctor’s patients qualified and received home-health services under Medicare. Additionally, the doctor and her co-conspirators actually paid patients to sign-up and recertify for home health services when those services were frequently medically unnecessary, not provided, or both. The evidence also showed that the doctor charged home health agencies an illegal kickback fee for certifying and recertifying patients for home health services. The four and one-half year-long scheme resulted in approximately $16 million in false and fraudulent claims for home-health services to Medicare.
Several other co-conspirators have now pleaded or been found guilty at trial based on their participation in the fraudulent scheme. Others have also been charged, found guilty, or pleaded guilty to conspiracy to commit healthcare fraud and/or pay or receive kickbacks.
A date for sentencing the doctor has not yet been set.
Compliance Perspective
Failure to monitor a healthcare provider who fraudulently bills Medicare for patient services that are medically unnecessary or not provided and also charges patients a “kickback” fee for certification or recertification for Medicare may be considered a violation of the federal False Claims Act and the Anti-Kickback Statute, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures for monitoring the services provided by physicians to residents to ensure that they are medically necessary and that they are actually provided.
- Train staff to be aware of services provided to residents by outside healthcare providers and to report any concerns about medically unnecessary services to their supervisor or through the Hotline.
- Periodically audit by interviewing residents about services provided to them through outside healthcare providers to ensure that the healthcare provider is not submitting fraudulent claims to Medicare.
FRAUD MODULE 3: MASTERING LEGAL IMPLICATIONS AND ANTITRUST LAWS
