Up to No Good

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close up of word medicare block letter

A typical day for doctors includes visiting patients, documenting notes, and writing prescriptions. However, a typical day for Dr. Thomas M. Prose, owner of General Medicine, P.C., in Novi, Mich., included filing thousands of false claims with Medicare. (Sounds like he wrote a few prescriptions for fraud.)

Since 2016, Prose and 17 other living communities and nursing homes billed Medicare for visits that were unnecessary, not performed, and did not meet the billing codes requirement. The six-year-scheme resulted in Medicare doling out $40 million dollars to the fraudsters. (That’s like winning the lottery but instead of risking the loss of his own money, the doctor was up to no good when he stole American taxpayer money.)

The 96-page complaint from the Department of Justice stated that Prose hired nurse practitioners and doctors to treat patients. The healthcare professionals (if you can call them that) performed tests that were not necessary. Administering these tests allowed the medical practice to reach visit quotas. (It was all about the numbers, not the patients.)

As if that were not bad enough, the fraudsters exaggerated their notes to suggest that the patient visits were more comprehensive. This false information allowed the defendants to use billing codes that would provide higher reimbursement rates. (That’s where the $40 million came from.)

Prose and his accomplices submitted false claims in multiple states including, Illinois, Kansas, Michigan, Louisiana, Iowa, Ohio, and North Carolina. (It seems like Prose had a goal of committing fraud in every state).

Prose received warnings that the visits did not properly meet the billing codes. Despite this, General Medicine continue finding ways to deceive the system. (One thing you have to admire about criminals is their perseverance.)

Apart from Dr. Prose’s imminent doom, two former General Medicine nurse practitioners are also in trouble. Jami Mayhew pled guilty in 2020 to healthcare fraud and Phillip Greene was indicted in September 2021.

Mayhew admitted to submitting 251 false claims to Medicare. General Medicine paid Mayhew $27 for every false claim she submitted. (Looking back, I bet that this fraudster won’t think that the $6,777she made off of this scam was worth it when she’s peering out from behind jail bars.) As for the leader of this scheme, Prose has not been found guilty. (Now we must wait in anticipation to see if he will join Mayhew in jail.)

Today’s Fraud of the Day comes from a McKnight’s article, “DOJ alleges $40 million Medicare fraud scheme tied to assisted living, nursing homes,” published on April 5, 2022.

A $40 million Medicare fraud scheme involving assisted living communities and nursing homes includes the submission of thousands of false claims across several states over six years, according to the Department of Justice.

The department said Friday that it had filed a 96-page complaint under the False Claims Act against Thomas M. Prose, M.D., owner of Novi, MI-based General Medicine, alleging widespread healthcare fraud involving the submission of thousands of false claims to the Medicare program. The company employed physicians and nurse practitioners to treat long-term care residents and patients in several states, including Illinois and Missouri.

 

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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.