Articles Posted in Health Care Fraud

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Lester and Nancy Sadler, a husband and wife, ran a series of pain management clinics in Ohio.

As the Sixth Circuit explained, “these were not conventional plain clinics.” For example, at one clinic

patients would arrive well before it opened, filling the clinic’s parking lot and the lots of nearby businesses. While waiting for the clinic to open, the patients used drugs and traded prescription forms for cash in the parking lots. The patients often traveled long distances (and in large groups) to come to the Sadlers’ shops, sometimes as much as 316 miles in a roundtrip, even though most of the patients lived much closer to other clinics.

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Hiring is always hard, especially in a small office.

You have work that needs to be done. You can’t do it all. Maybe you’re a professional, like a doctor, and some of the work isn’t the best use of your time.

So you hire someone to help. Really, how much do you know about a person as the result of a hiring process? Yet, despite that, you give them responsibility over a portion of your business.

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Two doctors, married to each other, were accused of health care fraud. They pled guilty and fought at sentencing about the amount of the restitution that they would have to pay back to the insurance companies for what they did. And, in United States v. Sharma, the Fifth Circuit held that a district court can’t just make up a restitution number.

Dr. Arun Sharma and Dr. Kiran Sharma ran two pain management clinics in Texas.

1028452_syringes_and_vial.jpgAt these clinics, the Doctors Sharma would give pain injections to patients. The health care fraud involved “paravertebral facet-point injections.”

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Alfred Caronia was a sales rep for a pharmaceutical company. And, despite what you might think by reading some of the literature, being a pharmaceutical sales rep is not a crime. It’s even more emphatically not a crime after the Second Circuit’s opinion in United States v. Caronia.

1213599_pills.jpgPart of Mr. Caronia’s job was to encourage folks to buy Xyrem.

According to the Second Circuit,

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When a person is convicted of a federal crime, especially in a fraud case, but in lots of other kinds of federal criminal cases too, the district court sometimes also orders that the person pay restitution.

The point of restitution is that the person has to pay back any money that they took – they have to make any victims of the crime whole again.

To satisfy a restitution judgment, the federal government can go try to get that money from assets that a person has – they can go after bank accounts and retirement accounts and houses.

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Medicare is a huge federal program. It’s also a huge source of criminal liability for doctors and other health care providers, as they try to comply with the byzantine regulations for billing issued by the Centers for Medicare and Medicaid Services.

Take United States v. Jones as an example.

1334532_ambulance.jpgStatewide Physical Medical Group

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Medical supplies are big business. Sadly, where there’s big business, there’s big money, and, often, there’s big law enforcement attention.

Geff Yielding worked as an assistant for a surgeon, Dr. Jordan, in Little Rock Arkansas. His wife, Kelley, started a company called ANI, that was in the medical services business. She became a sales agent for two bone-related medical supply companies. As such, she was paid on commission based on the number of sales she generated to surgeons.

image1Dr. Jordan used a nurse named Jordan Wall to order his supplies. Mr. Wall was an employee of the hospital where Dr. Jordan practiced.

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There’s a story out of Connecticut that I find particularly troubling; a woman has entered a guilty plea to obstruction of justice after lying to federal agents in a health care fraud investigation. To my mind, obstruction of justice charges have one cause – failing to hire a lawyer when you need one.

Too many people think they can go it alone in a federal investigation and wait to hire a lawyer. This is a mistake. To be sure, there are drawbacks to hiring a lawyer – lawyers are expensive, they take time, they tell you things you may not want to hear. But they also can advise you how to act when you, or someone you know, is caught up in an investigation.

The woman in this story said she lied about whether a patient signed an admissions form. One may think that some folks are liars and some folks aren’t and that hiring a lawyer won’t make a difference. I disagree. A good lawyer can intelligently explain why lying is a remarkably bad strategy when you’re caught up in an investigation.

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Sorry to have been off line recently; technical updates have been happening. All in an effort to give you a better Kaiser blog experience.

Doctors cannot bill Medicare for holding a stethescope up to the air, it has to be used to evaluate a patients health.
I wanted to quickly note that the New York Times ran an AP article last week revealing that the health care fraud prosecutions are continuing. Thirty more people have been rounded up and arrested, allegedly for committing Medicare Fraud.

The article says that doctors were giving “arthritis kits” that consisted of heating pads and braces. And that was just for the lucky ones who got a kit.

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The Eleventh Circuit recently decided a case that highlights why responding to a grand jury subpoena needs to be taken seriously. The case is United States v. Hoffman-Vaile. As a teaser, a doctor is going to prison for longer than she should because of how she handled a grand jury subpoena.

In the case, a doctor, Dr. Hoffman-Vaile, was being investigated for upcoding a series of dermatological procedures. Basically, the doctor was billing Medicare for a surgical procedure called “an adjacent tissue transfer or rearrangement that measures more than 30 square centimeters and is unusual or complicated.” This procedure was billed under code 14300.

The government’s suspicion was that Dr. Hoffman-Vaile using the billing code 14300, but, in fact, she was do a simpler dermatological procedure, with a different billing code. Telling Medicare that you’re doing a procedure that pays better than the one you’re actually doing is called “upcoding,” and it’s one form of medical billing fraud.