Medicare Menaces

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A health care provider’s dedication to good care—guiding the patient toward the right service vs. the wrong one—can sometimes mean life or death (especially when the patient is elderly). So it’s particularly troubling to hear of health care workers who actively blurred these lines for their own financial gain. A recent report by the Empire State News spotlights a New York-based clinic that billed millions of dollars to Medicare for services it had sold to its elderly patients, but that either were not medically necessary, did not qualify for reimbursement or, in some cases, were never even provided.

According to the report, this group of health care workers, including a licensed occupational therapist and a licensed chiropractor, submitted to Medicare upwards of $4 million in fraudulent claims for services, such as occupational and physical therapy and chiropractic sessions. (The crooked treating those in need of some simple straightening.) When it came down to actually providing some services, they pulled a bait and switch and passed off the patients to unlicensed therapists (as if we can just trust our necks and spines to just anyone) for massages or for other free treatments or goods. In some of the false claims, the workers listed the unlicensed therapists as ”licensed” or as practicing in the United States when they were not, or they concocted nonexistent visits with patients who weren’t even in the country during their ”appointments.” (Perhaps trying all the scams at once to see which one work best?)

When their scheme was discovered, the clinic workers ceased seeing patients and instead were given appointments with a federal judge on charges of conspiring to commit health care fraud. In addition to serving prison time), they each now owe the federal government a hefty sum of cash. The group’s organizer was sentenced to 42 months in prison and ordered to forfeit two properties worth more than $1 million; the licensed occupational therapist was given a 16-month prison sentence and ordered to pay more than half a million dollars in restitution; the licensed chiropractor received a 13-month sentence and ordered to pay $70,000 in restitution; a physical therapist received a 13-month sentence and was ordered to pay $985,501 in restitution; and the clinic’s manager received an eight-month sentence and was ordered to pay $115,136 in restitution.

Unlike most health care workers, these health care workers provided the opposite of ”care”: They actively worked against the patient’s best interests, first by failing to provide them with necessary services, and then by stealing limited funds specifically allocated for Medicare beneficiaries. The Department of Health and Human Services Office of Inspector General has shown that it’s no slouch when prosecuting such crimes.

Source: Today’s ”Fraud of the Day” is based on, ”Clinic owner and others sentenced for Medicare fraud,” an article written by Jason Greenberg and published by Empire State News on February 25, 2016.

From approximately December 2010 through June 2013, the defendants submitted more than $4 million in false claims to Medicare for physical therapy, occupational therapy, and chiropractic services that were not medically necessary, were often not provided, and otherwise did not qualify for reimbursement. Instead of evaluating and performing therapy and services on Medicare beneficiaries in the amount claimed, the defendants typically ushered them to unlicensed massage therapists for massages and other free goods and services. On some occasions, the defendants submitted claims to Medicare for services ostensibly performed by a licensed professional when that licensed professional was not even in the United States, or submitted claims to Medicare for services performed on Medicare beneficiaries who were abroad.

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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.