Two Montana nurse practitioners were sentenced on July 30, 2021, for conspiracy to defraud Medicare of millions of dollars. In addition to their prison time, one defendant was ordered to pay $4,307,934.58 in restitution and the second defendant was ordered to pay $5,054,866 in restitution.
In court documents filed in one nurse practitionerās case, the government alleged that from November 18, 2017, through July 16, 2019, the nurse practitioner worked with certain staffing and telemedicine companies to commit healthcare fraud and received money to sign brace orders that were prepared by telemarketers who had no medical training or certification. The nurse practitioner routinely signed these orders for Medicare beneficiaries regardless of medical necessity. She signed approximately 7,673 brace orders, which resulted in $8,259,849 billed to Medicare, of which Medicare paid approximately $4,307,934. She was paid at least $94,395 for the orders she signed.
In court documents filed in the second nurse practitionerās case, the government alleged that from October 15, 2017, to April 24, 2019, the nurse practitioner worked with certain staffing and telemedicine companies to commit healthcare fraud and received money to sign unnecessary brace orders for Medicare beneficiaries regardless of medical necessity, often without ever talking to the Medicare beneficiary to determine whether the braces were medically necessary. He signed approximately 7,097 brace orders, which resulted in $10,055,436 billed to Medicare, of which Medicare paid approximately $5,054,866. He was paid at least $124,900 for the orders he signed.
The female defendant was sentenced to 12 months in prison, and the male defendant was sentenced to 9 months in prison. Both defendants previously pled guilty to conspiracy to commit healthcare fraud.
Issue:
All medical orders must be medically necessary in order to bill Medicare, Medicaid, and other private insurance. The healthcare team should be knowledgeable in determining medical necessity. Ordering and billing for medications, tests, procedures, and durable medical equipment that are not medically necessary can be seen as fraudulent billing or submission of false claims. More information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 2 Financial Integrity, Policy FI 2.1 Billing Management.
Discussion Point:
- Review your policy and procedures on billing practices. Update as needed.
- Train staff on determining when a test, procedure, medication, or durable medical is medically necessary. Additionally, train appropriate staff on your policy and procedure for billing practices. Train all staff that suspicion of fraudulent billing practices must be reported and how to make a report directly to a designated person such as the compliance officer or through the use of the Hotline. Document that these trainings occurred and file each signed document in individual employeeās education file.
- Periodically audit to ensure that physician/nurse practitionerās orders are medically necessary. Survey professional staff on their knowledge on what can be considered medically necessary. Query staff to learn their level of understanding in the process for reporting concerns.
