Overinflated

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Young female caregiver helping senior woman walking down stairs at home

A Newton, Massachusetts doctor submitted overinflated claims to Medicare and MassHealth, the Massachusetts Medicaid program, for care he supposedly provided to nursing home patients. The consequences of his overblown actions require him to pay the two government healthcare programs $680,000 to resolve allegations that he violated the False Claims Act and committed healthcare fraud.

The Massachusetts doctor, who treated patients in long-term care facilities for approximately three decades, was audited by MassHealth. (This is the reason why his overinflated healthcare fraud scheme eventually burst.) Auditors examined nearly six years of claims for nursing home care that revealed false procedural codes and overestimations for how long certain services were provided to the residents.

Today’s article states that MassHealth requires providers to adhere to limitations on the number of billable visits allowed. (Apparently, only one evaluation was allowed per month, unless there was an emergency.) The Newton doctor didn’t abide by those limitations and billed for multiple visits even though they were not for emergency care. (In fact, 2,272 of those claims were not for medical emergencies.) He also neglected to use the correct codes when his non-physician employees provided care. (This means that MassHealth paid more than they should have for the services provided.) The audit report also stated that the doctor billed for more than $15,000 in services that supposedly occurred while he was overseas on 10 separate occasions.

As if this were not enough, the government determined that the doctor didn’t provide satisfactory oversight for his staff when prescribing medications. (His nurse practitioner and physician’s assistant dispensed 657 prescriptions with about one-third of those for narcotics including fentanyl, oxycodone and methadone.) Interestingly enough, the doctor told the auditors that he was not aware with the guidelines established by MassHealth, which is interesting because he had been practicing medicine for more than 30 years. (Fraudsters think they are special and immune to rules put in place to protect vulnerable citizens.)

Ironically, the doctor’s last name is Poor. While Dr. Poor enriched himself with funds intended for government healthcare beneficiaries, he will now have to pay back $265,896 to the Medicare program and $414,103 to the MassHealth program. (Easy come. Easy go.) He has also agreed to participate in a comprehensive compliance program which requires him to rectify some of the problems that were discovered during the audit in regards to policies, procedures, employee training and billing practices. (Let’s just say that it was a good move on his part to comply.) I hate to burst his bubble, but it looks like he’ll be watched pretty closely from here on out as he’ll be subject to annual on-site audits for the next three years.

Today’s “Fraud of the Day” is based on an article, “Newton Doctor Accused of Fraud To Pay $680K In Settlement,” posted on Patch.com on February 21, 2019.

NEWTON, MA – A Newton doctor has agreed to pay $680,000 to resolve allegations that he violated the False Claims Act by submitting inflated claims to Medicare and the Massachusetts Medicaid program (MassHealth) for care to nursing home patients, the US Attorney’s Office and the Attorney General announced Thursday.

“This doctor stole hundreds of thousands of dollars from MassHealth – taking away health care resources for those who are most in need,” said Attorney General Maura Healey in a statement. “We will continue to take action to defend the integrity of MassHealth and protect Massachusetts residents.”

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.