Wednesday, March 7, 2018

Florida Physician and Ex-Wife Indicted in Health Care Fraud Conspiracy For Alleged False Claims to Medicare and Blue Cross Blue Shield for Allegedly Using False Diagnoses of Rosacea, Acne, and Actinic Keratosis to Perform Chemical Peels, Dermabrasions, and Acne Surgery

The world of private insurance billing has changed in that federal and state authorities will be brought in for claims of insurance fraud. In the old days, if a claim was denied it was denied. If it was approved, that was the end of it. 

There are dermatology and plastic surgery physicians who understand what procedures are covered (rhinoplasty due to deviated septum/sleep issues, laser treatments for serious rosacea or acne scars, etc.)where those procedures will also improve appearance.  There are other patients and physicians who push the envelope to create a diagnosis in order to get insurance reimbursement.  

The issue is where is the line? How far should doctors go to help patients get insurance coverage for cosmetic treatments? In today's world, a recent case can show the legal issues present when patients' insurance is billed for for cosmetic procedures.

On or about February 26, 2018, Erik M. Schabert, 48, a physician, and his ex-wife, Mika Kamissa Harris, 49, both from Gainesville, Florida, surrendered on a federal indictment charging them with health care fraud and conspiracy to commit health care fraud.  The indictment also charges Harris with multiple counts of money laundering which shows how charges can be added for simply using funds that were obtained from billing for non-covered services.  The case is pending in the Northern District of Florida.

The indictment alleges that Dr. Schabert owned and operated Reliant Family Practice in Gainesville with his then wife as office manager.  It is also alleged that Ms. Harris provided cosmetic services during the same time period and had opened companies Naki Skin Care LLC, About Skin LLC and Noma Holdings LLC. One of the issues here will be whether the cosmetologists who performed some of the procedures can do so where it is billed by the medical provider.

Blue Cross and other private and government insurers do not reimburse medical providers for cosmetic surgery and procedures that are done "solely" for improving appearance.  While there are medical procedures that will have the added benefit of improving appearance, the issue is whether there is medical necessity and whether the services meet the ICD-9 codes billed.  This will be a factual and legal issue in this case.

The government alleges that Ms. Harris and Dr. Schabert defrauded health care benefit programs of $4.4 million through the submission of fraudulent claims by essentially billing for cosmetic procedures that were not covered.  According to the indictment, between January 2013 and July 2016, they allegedly caused claims to be submitted to Medicare and Blue Cross Blue Shield for chemical peels, dermabrasions, and acne surgery using false diagnoses of rosacea, acne, and actinic keratosis. There were also allegations of falsifying medical records to justify the services provided and billed.

An indictment is merely an allegation by a grand jury that a defendant has committed a violation of federal criminal law and is not evidence of guilt.  All defendants are presumed innocent and entitled to a fair trial, during which it will be the government’s burden to prove guilt beyond a reasonable doubt at trial. The trial is scheduled for April 24, 2018 which will probably be continued.

Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law


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