A federal jury convicted a Michigan man for his role in devising and executing a $1.8 million scheme to defraud Medicare by billing for services under another doctor’s name after Medicare revoked his privileges to participate in the program. The defendant was also convicted for falsification of records designed to prevent detection of this fraud and aggravated identity theft for falsely corresponding with Medicare under the name of another physician.
According to court documents and evidence presented at trial, the podiatrist was revoked from participating in the Medicare program in January 2015. Shortly thereafter, he convinced his then-partner to enroll in Medicare and assist in opening a new clinic. Once the new business was set up, he continued to bill Medicare for services just as he had prior to his revocation, only now exclusively under the name of his partner. Upon law enforcement’s discovery of this scheme, Medicare suspended payments to the clinic. The podiatrist then submitted false statements to Medicare regarding the fraud allegations (again, under his partner’s name) in an effort to undermine the government’s investigation and ensure the release of Medicare funds to the bank account he controlled.
The podiatrist was convicted of one count of conspiracy to commit healthcare fraud and wire fraud; three counts of healthcare fraud; one count of falsification of records in a federal investigation; and one count of aggravated identity theft. He is scheduled to be sentenced on Jan. 26, 2023, and faces a maximum penalty of imprisonment of 20 years for conspiracy to commit wire fraud and wire fraud, 10 years for healthcare fraud, 20 years for falsification of records, and two years for aggravated identity theft (to be served consecutive to any other sentence). A federal district court judge will determine any sentence after considering the US Sentencing Guidelines and other statutory factors.
The Office of Inspector General (HHS-OIG) and Homeland Security Investigations (HSI) investigated the case.
Issue:
The US Department of Health and Human Services (HHS) Office of Inspector General (OIG) has the authority to exclude individuals and entities from federally funded healthcare programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud. Those that are excluded can receive no payment from federal healthcare programs for any items or services they furnish, order, or prescribe. OIG maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires or partners with an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, healthcare entities should routinely check the list to ensure that new hires and current employees are not on it.
Discussion Points:
- Review your policies and procedures for screening of potential employees to confirm that they are not included on a state or OIG exclusion list. In addition, review your policies and procedures for frequency of checking the OIG Exclusion List for all current employees and vendors. Update policies as necessary.
- Train all appropriate staff on the requirement for checking the OIG LEIE link for all new potential hires, current employees, and vendors, and the frequency for repeating the checks. Document that the trainings occurred and file the signed document in each employee’s education file.
- Periodically audit to ensure that all new employees have been confirmed as not being on the OIG LEIE. Also, determine that routine checks are being conducted for current employees to ensure that they have not been added to the OIG Exclusion List. Ensure that a copy of the OIG LEIE screening confirmation is included in each employee or vendor file.
