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, Senior Director of Strategic Alliances, LexisNexis Risk Solutions - Government

Larry Benson is responsible for developing strategic partnerships and solutions for the government vertical. His expertise focuses on how government programs are defrauded by criminal groups, and the approaches necessary to prevent them from succeeding.

Mr. Benson has 30 years of experience in sales and business development. Before joining LexisNexis® Risk Solutions, he spent 12 years founding and managing two software technology startups. During the 1990s he spent 10 years as a Regional Director helping to grow a New England-based technology company from 300 employees to 7,000. He started his career with Martin Marietta Aerospace working on laser guided weapons and day/night vision systems.

A sought-after speaker and accomplished writer, Mr. Benson is the principal author of “Fraud of the Day,” a website dedicated to educating government officials about how criminals are defrauding government programs. He has co-authored WTF? Where’s the Fraud? How to Unmask and Stop Identity Fraud’s Drain on Our Government, and Data Personified, How Fraud is Changing the Meaning of Identity.

Benson holds a Bachelor of Science in Physics from Albright College, and earned two graduate degrees – a Master of Business Administration from Florida Institute of Technology, and a Master of Science in Engineering from Lehigh University.