A DAM Shame

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close up of word medicare block letter

There’s fraud, worse fraud, and then there’s healthcare fraud that endangers patients. James Spina, a chiropractor from Middletown, New York, embraced them all in a scheme that cost Medicare and other insurers millions of dollars in fraudulent claims—and left the one unfortunate patient dead.

Spina ran Dolson Avenue Medical (DAM), a medical clinic supposedly providing pain management and rehabilitation service including physical medicine and rehabilitation, chiropractic services, physical therapy, and acupuncture in Middletown. At least eight other corporations billed Medicare and other insurance providers from the same address. (What a coincidence!) The paperwork showed these “associated businesses” were owned by other medical professionals, but Spina and his co-defendant were the actual owners.

The schemers recruited medical doctors and other professionasl to pose as the owners and transferred funds from the fraudulent businesses to other companies they owned to conceal their ownership. The money came from fraud that included billing for services that were not medically necessary, and services never even provided to patients, in some cases. They also used the various associated businesses to submit multiple insurance claims for the same treatment. (Sure, if a little fraud works, a lot must work better.) Along the way, they altered and fabricated medical records, and obstructed audits by Medicare and other Insurers. (Again, they evidently felt more fraud was better.)

Worst of all, they subjected patients to dangerous procedures from an unqualified provider. One of the doctors working for DAM performed lucrative procedures called facet injections, which involved high-risk injections near the spinal cord. The unethical doctor “taught himself” the technique by watching other doctors and YouTube videos. (You know, like you might teach yourself to pilot a jet by watching YouTube, or maybe defuse a bomb.) Spina continued to encourage the procedure even after several patients suffered serious injury from the procedure, and one died from complications of a facet injection. (Can you spell“ malpractice?)

In May 2019, Spina pleaded guilty to one count of conspiracy to commit healthcare fraud. On April 13, 2021, he was sentenced to nine years in prison, followed by three years of probation. The Court also ordered $9,760,555.20 in restitution, and forfeiture of another $9,105,741.61 of fraudulent gains. (Maybe he can spend some of that prison time learning about ethics on the Internet.)

Today’s Fraud of the Day comes from a press release from the United States Attorney’s Office for the Southern District of New, “Doctor Sentenced To 9 Years In Prison In Widespread Scheme to Defraud Medicare and Other Health Insurance Providers of Millions of Dollars,” dated April 13, 2021.

Audrey Strauss, the United States Attorney for the Southern District of New York, announced today that JAMES SPINA was sentenced to 108 months in prison for his participation in a widespread health care fraud scheme through the fraudulent operation of Dolson Avenue Medical (“DAM” or the “Practice”), a multi-disciplinary medical clinic located in Middletown, New York.  SPINA previously pled guilty before U.S. District Judge Kenneth M. Karas, who imposed today’s sentence.

U.S. Attorney Audrey Strauss said: “James Spina led a sophisticated, widespread, and callous scheme that put greed and profits ahead of patients and their well-being.  In doing so, he betrayed his professional obligations and bilked insurance companies and Medicare out of millions of dollars.  Thanks to the coordinated efforts of federal and state investigative agencies, Spina will now serve a lengthy sentence in federal prison.”

 

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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.