California Business Partners in Home Health and Hospice Businesses Sentenced To 33 Months In Federal Health Care Fraud Case. One Partner Was Previously Excluded From Medicare By OIG.

Home health and hospice fraud cases are still priorities in the Justice Department. On April 18, 2019, a former California medical doctor Camilo Q. Primero, age 76, and his business partner Aurora S. Beltran, age 63,were sentenced to 33 months in prison for their individual roles in an alleged Medicare health care fraud case involving three Las Vegas hospice and home healthcare agencies. Both individuals plead guilty and were sentenced following their pleas to conspiracy to commit health care fraud and money laundering.

One of the allegations was that Mr. Primero was excluded from Medicare by the Office of Inspector General and should not have been an owner of any of these health care businesses which were billing the Medicare program. When an excluded individual owns the business all monies billed to the program are potentially recoverable. If the government alleges a "sham" owner, there is the potential of alleging the entire business is a fraud since the government would not have approved the application if it knew that one of the "real" owners was excluded by OIG.

In the plea agreement, they admitted that they filed false enrollment documents with Medicare to enable Mr. Primero to operate hospice and home care agencies through nominees despite his prior exclusion from all federal health care programs. Furthermore, they admitted they submitted fraudulent hospice care claims for people who were not terminally ill and did not require hospice care.

Sacramento Area Neurosurgeon Charged With Workers' Compensation Fraud and Insurance Fraud For Alleged Upcoding and Ghost Billing For Services Not Provided

On April 9, 2019, Dr. Laura Anderson, a neurosurgeon from Carmichael, California, was charged with multiple counts of medical insurance fraud, workers’ compensation fraud, and grand theft. A felony complaint is not evidence and Dr. Anderson is presumed innocent.

The prosecution alleges that from 2013 to 2018 Dr. Carmichael changed the coding of bills ("upcoding") for X-rays and telephone consultations in order to obtain higher reimbursement. It is also alleged that there was billing for medical services not provided to patients whose workers' compensation was covered by the State Compensation Insurance Fund (SCIF). 

Attorney Commentary: One issue with physicians and other health care providers billing workers' compensation is that when it is on a lien basis, the billing is often charged and handled differently than regular insurance billing. Due to the length of time getting paid and the negotiated, litigated amounts, medical billers have been more aggressive and this can cause problems for physicians when improper coding is used. Often physicians leave it to office staff and medical billers and have problems years' later. There are many laws and regulations that govern the disclosure of medical billing and reports in workers' compensation in California. 

Physicians and health care providers should have a compliance plan for workers' compensation billing and collection since insurance carriers can be very aggressive and report claims to the local District Attorney's Office who have designated prosecutors paid out of state fund for workers' compensation.

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

Louisiana Neurologist Who Allegedly Pre-Signed Prescriptions for Controlled Substances Is Charged With Conspiracy to Unlawfully Dispense Controlled Substances and Health Care Fraud

A pain management neurologist has been charged with unlawful prescribing and health care fraud conspiracy relating to Medicare billings for the prescriptions billed to Medicare. This is an extension of government theories since as the prescribing physician, the pharmacy would have received the payments and and not the neurologist. The pharmacy has its own corresponding duties to Medicare. 

However, the twist here is that the government alleges that the prescriptions were pre-signed by the neurologist and that he did not see the patients. However, it is not clear if any other providers saw the patients or who else completed the prescriptions. One would assume there must be other facts relating to this pain management clinic that are not alleged in the charging documents.

On April 18, 2019, a two-count bill of information was filed against neurologist Anil Prasad, M.D., charging him with conspiracy to unlawfully dispense controlled substances and conspiracy to commit health care fraud. If Dr. Prasad does not waive Indictment or reach a plea agreement, there will probably be an Indictment arising from the information. An information is a charging document and is not evidence and Dr. Prasad is presumed innocent of all charges. 

Specifically, Dr. Prasad was charged with one count of prescribing controlled substances outside the course of professional practice and for no legitimate purpose and one count of conspiracy to commit health care fraud.  According to court documents, between November 2016 and July 2018, Dr. Prasad worked at a pain management clinic in Slidell, and during the course of his employment he pre-signed prescriptions for controlled substances, including oxycodone and hydrocodone, without performing patient examinations to determine medical necessity.

Colorado Doctor Convicted Of Health Care Fraud and Obstruction of Justice. Admitted Shredding Patient Charts During the Investigation.

A recent health care fraud trial focused on patients' insurance being billed for procedures not performed or with extensive patterns of upcoding as well as obstruction of justice for shredding charts during the investigation. On April 18, 2019, Dr. John Van Wu of Golden, Colorado was found guilty of mail fraud and obstruction of justice charges by a jury. The federal jury trial lasted one week before U.S. District Court Judge R. Brooke Jackson.  

According to court records and argument at trial, Dr. Wu operated a medical clinic at locations in west Denver between January 2011 and March 2015.  During that time period the government alleged that he billed employee benefit programs and insurers for services that were never actually rendered and not medically necessary.  

The obstruction charge arose from when he responded to a grand jury subpoena asking for patient files.  During the trial, over a dozen of the doctor’s former patients testified that they did not have many of the ailments described in those files and did not get the expensive procedures billed to insurance.  For example, the patient files described days-long nosebleeds followed by nasal cauterization procedures, but patients testified that neither happened.  Other files described diagnoses related to migraine headaches and frequent administrations of injections to treat those agents.  Patients testified that those, too, did not occur.  The government alleged that the patient files were fabricated.

Testimony at trial also supported the government's theory that Dr. Wu billed approximately 95% of his office visits as the longest, most complex, and highest-reimbursing type of office visit, despite the fact that his patients had relatively simple and routine ailments that did not need that level of service.  During his testimony, Dr. Wu admitted that he shredded patient files while the investigation was ongoing.

This is not the end of Dr. Wu's legal issues. He is separately charged with distributing oxycodone outside the usual course of medical practice and for no legitimate reason and for obstruction by falsifying patient charts related to those prescriptions.  Trial on those counts is scheduled to begin on July 8, 2019.

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

Florida Gynecologist Who Treated Incontinence Sentenced to Federal Prison After Being Convicted at Trial of Health Care Fraud

Going to trial is a difficult choice for health care providers in paper fraud cases where there are numerous and obvious billing errors. The issue is usually whether the government can prove beyond a reasonable doubt that there was intent to defraud and not billing errors. A recent case shows what happened when a Florida physician went to trial, testified and lost at trial. Obviously, it was a very difficult decision for her and her family which included teenage children. The sentence was dispensed this week.

On April 21, 2019, Sheetal Kanar Kumar, M.D. of Stuart, Florida, was sentenced to a total of 24 months in prison, to be followed by 2 years of supervised release. This sentence came after a trial in February where a federal jury convicted her of committing 23 acts of health care fraud. She was acquitted of 6 counts of health care fraud. Dr. Kumar testified on her own behalf at trial. 

According to the court record, including evidence introduced at trial, Dr. Sheetal Kumar owned and operated the medical practice Advanced Healthcare for Women in Stuart, Florida.  Dr. Kumar was an obstetrician and gynecologist who treated incontinence.  Dr. Kumar testified at her trial and according to the press testified that she did not plan a fraud and if there were billing errors she should have been allowed to pay the amounts back before being indicted.  

From January 2014 until July 2017, the government alleged that Dr. Kumar submitted or caused the fraudulent submissions of claims to Medicare, Medicaid and private insurance companies.  The fraudulent claims sought money for specific health care benefits, items, and services that were not provided as billed.  As a result of such false and fraudulent claims, Medicare, Medicaid and private insurance companies, made payments in the approximate amount of $637,000.

Attorney Commentary: The problem with a felony case is that it is not just the conviction but the collateral consequences that will follow a professional for the next 5 to 10 years, long after any sentence is served. Whether it is loss of a professional license, exclusion from Medicare and Medicaid programs, loss of a DEA license, loss of insurance contracts, the list of effects goes on and on.  This is why anyone billing Medicare and Medicaid should have a compliance plan which will give a "safe harbor" and avoid the allegations of criminal fraud and keep the case in a civil and administrative place. 

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

Two California Brothers Plead Guilty in Conspiracy to Distribute Prescription Drugs Through Sham Medical Clinics That Hired Allegedly Corrupt Doctors

Physicians and other health care providers  should always be careful when answering advertisements for clinics, especially when run by non-physicians. One recent case shows what happens when physicians' identities were stolen for prescribing purposes. In addition, other physicians were hired and are facing their own issues.

On April 16, 2019, two Los Angeles area brothers Minas Matosyan (age 38) and Hayk Matosyan (age 32) pleaded guilty to federal criminal charges, admitting that they conspired to distribute controlled substances, such as hydrocodone and oxycodone via sham medical clinics that hired doctors who wrote fraudulent prescriptions to black market customers. 

According to the plea agreement, in May 2016, Minas Matosyan spoke with a doctor and offered him a “very lucrative position” where the doctor would “sit home making $20,000 a month doing nothing,” according to the plea agreement. After the doctor declined the offer, Minas stole the doctor’s identity, sending a co-conspirator a text message containing the doctor’s full name, medical license number and national provider identifier number that the co-conspirator used to order prescription pads in the doctor’s name. 

California Pharmacist Charged With Filling Fraudulent Prescriptions for Oxycodone and Hydrocodone.

The opioid prescription cases keep coming. On April 11, 2019, a Fresno pharmacist, Ifeanyi Vincent Ntukogu of New Life Pharmacy, in Madera was indicted one count of conspiracy to distribute and possess with intent to distribute controlled substances and 17 counts of distribution of controlled substances (oxycodone and hydrocodone). The charges are only allegations; the defendants are presumed innocent until and unless proven guilty beyond a reasonable doubt.

Two other non-medical persons to whom the medications were allegedly dispensed were also charged: Kelo White was charged with one count of conspiracy to distribute and possess with intent to distribute controlled substances and 12 counts of possession with intent to distribute controlled substances. Donald Ray Pierre was charged with one count of conspiracy to distribute controlled substances, 10 counts of possession with intent to distribute controlled substances, and two counts of identity theft. 

According to court documents, Mr. Ntukogu allegedly filled fraudulent prescriptions for oxycodone and hydrocodone, Schedule II controlled substances, at his pharmacy New Life Pharmacy between December 2014 and November 2018, and then dispensed the controlled substances to Mr. White and Mr. Pierre. 

Sutter Health LLC, a Medicare Advantage Provider, Pays $30 Million To Settle Alleged Overpayment Based on Beneficiaries' Health Status Risk Scores

It is not just fee-for-service providers that have audits and civil qui tam cases. Managed healthcare is facing review as well. Even providers who are paid capitation fees should be mindful of the codes submitted to managed care. A recent case illustrates why. 

On April 12, 2019, Sutter Health LLC, a California-based healthcare services provider, and affiliated entities (Sutter East Bay Medical Foundation, Sutter Pacific Medical Foundation, Sutter Gould Medical Foundation, and Sutter Medical Foundation) agreed to pay $30 million to resolve allegations that these affiliated entities submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans known as "risk scores," which allegedly resulted in the plans and providers being overpaid. Sutter Health is headquartered in Sacramento, California.  

   

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed healthcare insurance plans called Medicare Advantage Plans (“MA Plans”) that are owned and operated by private Medicare Advantage Organizations (“MAOs”).  MA Plans are paid a capitated, or per-person, amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. 

Federal Charges Can Come From Billing Private Health Insurance: San Francisco Acupuncturist Indicted On Health Care Fraud Charges For Alleged False Billing and Upcoding

We are seeing an increase in investigation of acupuncturists and chiropractors relating to billings to private insurance companies. The charges can result from upcoding, billing on the wrong dates, miscoding and other acts and omissions. There is a difference between fraud and billing errors. Criminal fraud cases require proof beyond a reasonable doubt of an intent to defraud.

Health care providers have often thought that if they are not billing Medicare or Medi-Cal, they will not be the subject of federal investigation. Now that private insurance is subsidized by the government for low income individuals, there is a significant push to investigate these cases. In addition, private insurance companies are submitting the cases for prosecution. One recent case shows what these cases can look like. It also show that coding matters and claim submissions if not accurate can lead to fraud allegations.

On March 7, 2019, a federal grand jury indicted San Francisco acupuncturist Haichao Huang, charging him with health care fraud and making false statements relating to health care matters.  An indictment is not evidence and Mr. Huang is presumed innocent. 

According to the indictment, the government alleges that from February 2013 through June 2018,  Mr. Huang, age 46, was a health care provider who offered acupuncture, physical therapy, massage, and other services at his office in San Francisco.  The indictment alleges that Mr. Huang submitted claims for reimbursement to his patients’ health insurance plans, claiming that he provided reimbursable services and treatments when, in fact, he knew that the billings were false and not properly reimbursable.  

The indictment gives three examples of the ways in which Huang allegedly submitted billings for reimbursement.  First, Mr. Huang allegedly submitted requests for reimbursement for acupuncture and other treatments when, in fact, the patient had received either much shorter periods of treatment or no treatment at all.  This could be an upcoding situation or what is called "ghost billing" (billing for service that was not provided).

Second, after a patient reached the limit of acupuncture sessions allowed by the relevant insurance plan, Mr. Huang allegedly billed the plan for other types of treatments and services that were not provided in order to continue receiving improper reimbursements.  

San Jose Doctor Pleads Guilty To Federal Charge of Unlawfully Distributing Hydrocodone and Committing Health Care Fraud. Make Sure Your Practice Follows California Pain Medication Guidelines.

Record keeping and following the California pain management protocols are key for physicians who prescribe scheduled medications for pain management. California revised its protocols called “Guidelines for Prescribing Controlled Substances for Pain” in November 2014 and expects all physicians to be familiar with it. You can download a copy of it with its attachments from the link above which is my public dropbox account. 

Under federal and state law, if the physical examination does not demonstrate legitimate medical need which must be documented, then the prescription is no longer protected by the DEA rules allowing physicians to prescribe. It is then treated like an illegal drug and opioids, like cocaine, are treated harshly under the sentencing guidelines. Even board certified pain management doctors need to be careful to make sure their record keeping and physical examination protocols are up to date. Every doctor can have a bad or busy day, but with scheduled drugs such allowances are simply not tolerated.  I recommend that doctors and clinics systemize as much as they can which is sometimes not done in small or solo practices. A recent case shows why this is so important.

San Jose pain management physician Venkat Aachi, indicted on October 9, 2018, has now pleaded guilty to distributing hydrocodone outside the scope of his professional practice and without a legitimate medical need, and to health care fraud. This is a huge blow to his practice and profession.  On March 26, 2019, his guilty plea was accepted by the Honorable Edward J. Davila, U.S. District Judge.