Diagnosis: Fraud


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Medical billers have to deal with a lot of numbers, so it’s easy to understand how a few digits could become transposed. A few wrong numbers could report an incorrect diagnosis and as a result, cause an incorrect insurance bill to be generated. (Obviously, this type of oversight is understandable. Everyone makes mistakes.) A Federal Bureau of Investigation press release tells about a medical biller for a Chicago-based physician practice who got creative with her billing procedures and submitted claims to Medicare for more than $4 million.

The release states that over four years, the woman served as primary medical biller for a medical practice that provided in-home visits to patients for the purpose of prescribing home health care. She and her co-conspirators billed Medicare for care plan oversight on a regular basis, even though the practice’s doctors rarely provided the services noted.

According to the press release, the medical biller got a little creative with her claims. Evidence presented at her trial showed that she purportedly billed Medicare for services provided to deceased patients, services provided by medical professionals no longer employed by the practice and for services allegedly provided by employees that worked more than 24 hours in a day. (That scam definitely took a bit more forethought to accomplish than simply transposing a few numbers.)

The 54-year-old was convicted by a jury trial on conspiracy to commit health care fraud, health care fraud and making false statements related to a health care matter. She was sentenced to 45 months in prison and ordered to pay $1 million in restitution. (Over five years, the medical biller caused more than $1 Million to be paid out by Medicare for the bogus claims.) One 58-year-old co-conspirator was convicted along with the woman and was sentenced to serve more than seven years in prison. Another co-conspirator, who happened to be the 64-year-old former Medical Director of the physician service, pleaded guilty to similar charges and is scheduled to be sentenced.

While medical billers are responsible for coding a patient’s diagnosis and submitting bills to insurance providers for reimbursement, the government is responsible for identifying fraud and making those individuals who are responsible for stealing from the government pay for their criminal deeds. Congratulations to the Medicare Fraud Strike Force for successfully prosecuting these three fraudsters, who join the list of more than 2,300 defendants who have billed the Medicare program for over $7 billion.

Source: Today’s ”Fraud of the Day” is based on a press release titled, ”Medical Biller Sentenced to 45 Months in Prison for Role in $4 Million Health Care Fraud Scheme,” released by the Federal Bureau of Investigation on September 18, 2015.

WASHINGTON—The medical biller of a Chicago-area visiting physician practice was sentenced today to 45 months in prison for her role in a $4 million health care fraud scheme.

Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Zachary T. Fardon of the Northern District of Illinois, Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG) in Chicago and Acting Special Agent in Charge John A. Brown of the FBI’s Chicago Division made the announcement.

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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.