The jig is up. At least it is for a podiatrist in Colorado. On Thursday, February 12, 2015, the physician in question pleaded guilty to one count of health care fraud. Through improper location coding, the podiatrist allegedly defrauded Medicare out of higher reimbursements.
According to The Daily Sentinel, the podiatrist is accused of performing services at a nursing home while claiming otherwise. The physician allegedly billed for services based upon location coding showing the patients were seen in his private office, not in the nursing facility in which they resided. In doing so, he received a higher reimbursement rate than he was eligible for.
The Logistics of The Scheme.
When registering to become a Medicare provider, physicians are required to provide the location at which they provide services. Then when the services are billed, a place of service modifier can be attached to the code (e.g., hospital, private office, assisted living facility, etc.) to determine whether the service qualifies for a bump in reimbursement. Services provided in an office setting typically receive reimbursements at a higher level in order to compensate for the overhead of the physician. Office expenditures such as rent, insurance, utilities and other cost associated with running a business are taken into consideration.
The podiatrist was allegedly granted three months of rent-free space at the nursing home to provide services for the residents. The physician, therefore, considered this to be enough to bill the office place of service modifier. According to court records, the space he practiced out of was actually a storage room/beauty salon of the facility.
The charging document claims that the physician improperly billed on only two dates of services. Reports differ on the amount of alleged fraud (some reports are as low as $2,000 while others are as high as $50,000). But regardless of the actual, this story goes to show that the federal government is not above felony prosecution for less than “blockbuster” amounts of fraud.
The Benefits Never Outweigh the Risks.
With the sentencing hearing in May, the physician could be sentenced to probation or a maximum of 10 year in prison, and fined up to $250,000. In addition, the podiatrist will no longer be permitted to treat Medicare patients. It is also possible that the podiatrist will be unable to retain his license to practice due to being a convicted felon and being placed on the OIG exclusion list.
If you are facing an OIG audit or investigation, you should immediately consult with an attorney experienced in handling those matters. Retaining experienced counsel in the early stages of an OIG audit or investigation can be of great assistance in resolving the case without criminal charges or placement on the exclusion list. Also, if you feel that your practice may be billing incorrectly for services, you should speak with an expert to determine the method and manner of any necessary repayment to the federal government.
To read the full story from The Daily Sentinel, click here.
To view court records of the case, click here.
One Last Thing.
We cannot stress enough the importance of properly registering your address with Medicare. The consequences can be damning to your career. Medicare exclusion will not only directly impact your bottom line, but it will also limit your job eligibility.
Have you ever run into an issue with your Medicare registered address? Did you know this was a surefire way to put yourself at risk? Please leave any thoughtful comments below.
Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent healthcare providers in reversing termination of Medicare billing privileges, preparation of corrective action plans (CAPs), requests for redetermination, hearings on Medicare terminations, Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.
About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.
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