It is no secret that the government will aggressively pursue allegations of healthcare fraud. In a recent example, the government built a case against a physician and healthcare employee who allegedly targeted elderly and disabled patients as part of a healthcare fraud scheme that cost the government millions. Those in the medical field are wise to know the basics of this case so they can take steps to protect themselves from similar allegations.
How the government build their case
The prosecution built their case using evidence centered on unnecessary lab testing and prescriptions directed to specific companies in exchange for kickbacks, plus bribes disguised as “rent” paid to adult day care owners for access to vulnerable patients. In addition to healthcare fraud charges the government also pursued charges for identity theft for forged patient signatures on consent forms. When reviewing the evidence, the jury found the physician and employee guilty and the judge sentenced the physician to 120 months and the employee to 97 months imprisonment along with mandatory restitution payments of over $3 million.
How the fact pattern created criminal liability
Two key allegations that are common in these types of cases include the use of medical necessity as a way to increase volume of claims, not a clinical judgment and remuneration tied to referrals, including “rent” arrangements lacking fair market value support. These allegations along with the presence of forged patient signatures strengthened the prosecution’s argument that the accused intended to defraud the government.
Practical steps to reduce exposure before an investigation
This case serves as a reminder of the need for physicians to maintain proper documentation, refer based on medical necessity and have measurable auditing practices in place that can withstand review in the event of an investigation. It is also wise for groups to regularly review contracts to help better ensure compliance with applicable regulations like the Anti-Kickback Statute. These steps can help to mitigate the risk of allegations of wrongdoing and provide the necessary documentation to build a defense in the event of an investigation.
Attorney John Rivas is responsible for this communication