A federal jury convicted a New York ENT doctor for defrauding Medicare and Medicaid by causing the submission of false and fraudulent claims for surgical procedures that were not performed.
According to court documents and evidence presented at trial, the doctor billed Medicare and Medicaid for an incision procedure of the external ear for hundreds of patients, when in fact all he actually performed was an ear exam or ear wax removal. Specifically, between January 2014 and February 2018, the doctor billed Medicare and Medicaid approximately $585,000 and was paid approximately $191,000. Medicare and Medicaid data demonstrated that he was identified as an outlier and the highest biller for this procedure in New York State.
He was convicted of one count of healthcare fraud and one count of making a false claim. He is scheduled to be sentenced on November 7, and faces a maximum penalty of 15 years in prison. HHS-OIG and OMIG investigated the case.
The HHS-OIG Fraud Section leads the Criminal Division’s efforts to combat healthcare fraud through its Health Care Fraud Strike Force Program, which since March of 2007 has charged more than 4,200 defendants who have collectively falsely billed the Medicare Program for more than $19 billion. The program is comprised of 15 strike forces that operate in 24 federal districts.
Issue:
False claims can be generated in a variety of capacities. It is important for staff to be aware that false claims can occur whether they are intentional or unintentional. Healthcare providers, suppliers, or other individuals or entities subject to Civil Monetary Penalties can use the OIG’s Provider Self-Disclosure Protocol to voluntarily disclose self-discovered evidence of potential fraud. Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a government-directed investigation and civil or administrative litigation. Self-disclosure with correction, when completed in a timely manner, may prevent reporting by a whistleblower that could result in greater sanctions and larger monetary penalties.
Discussion Points:
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected. Monitor your PEPPER (Program for Evaluating Payment Patterns Electronic Report) data to ensure your billing practices do not categorize your facility in an outlier category.
