Healthcare Compliance Perspective:
Medicare Fraud is knowingly submitting false claims to obtain Federal healthcare payments for services either no rendered or billed for at a higher complexity that services actually provided. Making claims for services either not provided or not provided by a required certified, licensed healthcare professional can result in false claims and constitutes healthcare provider fraud.
A 49-year-old man from Texas, who pled guilty in August 2017 to one count of health care fraud, was sentenced today by a U.S. District Judge to 41 months in federal prison and ordered to pay $514,576.29 in restitution, joint and severally with his co-defendant. The announcement was made last week by a U.S. Attorney of the Northern District of Texas.
As part of the plea agreement the former chiropractic clinic operator agreed to forfeit a total of $84,750.23, and to surrender to the Bureau of Prisons on January 9, 2018.
According to the plea agreement factual resume, from July 2012 through July 2015, the man operated a chiropractic clinic in Texas, without a license issued by the Texas Board of Chiropractic Examiners. A co-defendant assisted the man in billing insurance companies for services legally billable only by a licensed chiropractor. They also billed for services not rendered and for services rendered in lesser quantities billed.
The two defendants would deliberately omit the man’s name or national provider identifier on their clinic’s itemized billing statements. The pair also listed the specific type of procedure or service the clinic provided by misrepresenting to insurance companies that the procedures being billed were performed by a licensed health care provider in good standing with their state board.
An estimated $524,547.29 in payments was issued by health care providers to the clinic from 12 insurance companies.
