The number of prosecutions for health care fraud involving private insurance is on the rise as shown by a recent case.
In years past, the insurance carriers would have audited and demanded a repayment or cancelled their contract. That has definitely changed.
On May 11, 2017, a Fresno federal grand jury returned an eight-count indictment for health care fraud against dermatologist Dr. Basil Hantash who is the medical director of Advanced Skin Institute (ASI) in Turlock, California.
According to the Indictment from 2011 through April 2016, Dr. Hantash submitted claims to private insurance companies requesting payment for performing acne surgeries. It is alleged that staff at ASI had performed only "cosmetic" procedures known as microdermabrasions or chemical peels.
What is interesting about this is that "acne surgery" is often microdermabrasion or chemical peels. The difference between "cosmetic" and "medical" is whether there is medical necessity and whether the carrier will cover the dermabrasion or chemical peel. Acne surgeries often means marsupialization, opening or removal of multiple milia, comedones, cysts or postules to treat acne.
Some carriers take the position that dermabrasion or chemical peels to treat acne scars is cosmetic. The carriers also argue that active acne is not properly treated with dermabrasion. However, there may be grounds to show why dermabrasion or peels were used. This will be an expert issue. There may be an issue as well on whether unlicensed staff performed or if there were RNs under the physician supervision. The charts will be key to show what was done here and if there was a good faith billing error.
Two insurers, Anthem Blue Cross and Blue Shield of California, paid ASI a total of approximately $220,000 during that time for claimed acne surgeries. The charges are only allegations; the defendant is presumed innocent until and unless proven guilty beyond a reasonable doubt.
The U.S. Attorney's Offices were more focused on Medicare or other government billing in the past and did not see the federal interest in private insurance fraud. Health care insurance costs are now borne by the government with the Affordable Care Act and thus the government has a significant interest in fighting fraud and abuse.
Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law