The Manhattan U.S. Attorney recently announced civil and criminal health care fraud cases against a vascular surgeon out of Manhattan. According to the prosecution, the doctor fraudulently billed Medicare for vascular surgeries involving end-stage renal disease (ESRD) patients. The government states these procedures were not medically reasonable or necessary. As such, they did not fall within Medicare billing rules.
Medicare rules provide coverage for the procedures at issue, like fistulagrams, in certain situations — for example, if a patient is having difficulty receiving dialysis. In the absence of a qualifying situation, these procedures for ESRD patients do not qualify for payment through Medicare. The feds claim the physician fraudulently submitted claims for payment for procedures that did not qualify from 2015 through 2016. This led to over $1 million in allegedly fraudulent payments.
When presented with the evidence, the physician agreed to settle the claim. As part of the settlement, he will pay $783,200 to the feds as well as an additional $16,800 to New York authorities. He has also agreed to refrain from participation in federal health care programs like Medicare for at least four years.
This is the not the accused’s first run in with the feds over allegations of health care fraud. He was previously accused of fraudulent billing practices from 2010 through 2012. He also settled that claim. This previous history likely played a role in the steep penalties that went along with this settlement.
This case provides an example of the stiff penalties that can come with allegations of wrongdoing if there is a previous history of similar allegations. Those who are in this situation are wise to act promptly to protect their interests and build a defense to the claims.