Saturday, April 23, 2016

Georgia Doctor Pleads Guilty to False Billing to Private Insurers and Medicare for Surgical Monitoring Performed by Medical Assistant

Analysis of billing data is leading to more investigations, audits and prosecutions. Anonymous complaints to the HHS-OIG Hotline at 800-HHS-TIPS are also an increased source of investigations. One recent health care fraud case against a physician came about due to both analysis of billing data and anonymous complaints to the HHS hotline.

On March 25, 2016, Dr. Robert E. Windsor, an Atlanta-area physician, pleaded guilty to health care fraud for filing claims for surgical monitoring services he did not perform before U.S. District Court Judge Amy Totenberg.

According to the charges and other information presented in court: Dr. Windsor, a licensed Georgia physician, entered into a contract with American Neuromonitoring Associates, P.C. (ANA), a Maryland corporation, to provide a medical service called intra-operative monitoring. In this medical procedure, a physician monitors a patient’s nerve and spinal cord activity during surgery to reduce potential adverse effects to the patient.

The contract stated that Windsor would provide real-time monitoring services for patients in surgery via an online platform with technologists in the operating room. Windsor was responsible for providing a final monitoring report at the conclusion of each surgery, and ANA and its sister company would thereafter bill patients and health care benefit programs, including private health insurance companies, for the monitoring. Dr. Windsor was paid a fee for each surgery monitored.  

Between at least January 2010 through July 2013, Dr. Windsor instead assigned the monitoring to a medical assistant who impersonated Dr. Windsor by using Dr. Windsor’s log-in credentials in the online platform. The medical assistant was not a doctor and was not permitted to perform the monitoring under the contract with ANA. Dr. Windsor submitted final monitoring reports which by their nature falsely stated that he had conducted the monitoring, which ANA and its sister company relied upon in billing health care benefit programs for his services. On several occasions, Dr. Windsor allegedly billed ANA for monitoring services he purportedly performed when he was actually traveling on an international flight and this type of proof was used as an example of his conduct.

In total, after collecting reimbursements from insurers, it was alleged that ANA paid Dr. Windsor over $1.1 million for monitoring services he did not perform during this time period. Sentencing for Dr. Windsor is scheduled for June 3, 2016 at 10:30 a.m.

Attorney Commentary: Big data and billing data analysis is making audits for private and government carriers easier. I have seen an increase in the number of audits for even small providers since it is much simpler to see patterns in billing that trigger red flag audits. This ability to analyze billing data makes it more important than ever for providers to be compliant given that private insurers and government providers will pursue cases criminally if there is consistent billing for services not provided.  The old days of simply making an overpayment are going away.  The use of big data analysis, the allure of whistleblower lawsuits and anonymous complaints are also reason to self-report when appropriate.  


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