Choose Your Partners Wisely

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Shot of a woman assisting her elderly patient who's using a walker for support

When choosing a business partner, it’s important to find someone that can bring their skills and experience to the company. You’d also want someone that shares your values and vision and can offer resources and credibility. When an optometrist at Outreach Diagnostic Clinic in Houston, Tex. realized that his partners did not operate by the same ethics, he blew the whistle on them for using illegal billing practices.

Dr. Mustapha Kibirige, 58, and Dr. Emelike Agomo, 57 were two ophthalmologists who worked at Outreach Diagnostic Clinic, providing care for patients diagnosed with glaucoma. The two doctors allegedly fraudulently billed the Medicare Program for single eye pressure measurement tests used to assess and treat the disease. (Those tests are the ones that blow puffs of air into your eyes. Definitely not my favorite eye test.)

The two doctors purportedly performed the puff test, which was billed under one code, but billed as if it were an imaging scan of the retina, which was billed under a higher reimbursement rate. In total, the clinic submitted 14,450 claims between 2006 and 2012 under the higher billing rate. They received $807,450 in Medicare payments.

The whistleblower, who was the former employee mentioned, filed a lawsuit under the False Claims Act (FCA), which is the primary litigation tool for combatting fraud against the Federal Government. Under the FCW, a private party can file an action on behalf of the U.S. and receive a share of the recovery. Judging by the size of the settlement, the whistleblower probably got a nice chunk of change for his part in bringing down these unscrupulous individuals.)

The Federal Government won a summary judgment against the clinic, and the judge assessed a penalty of treble damages of $2,422,350 and a penalty of $11,803 for each claim submitted or $170,553,350. (Yes, you read that right – more than $170 million. Those doctors are going to have to sell a lot of pairs of glasses to pay back that amount of money.)

In this case, it is important to remember that the claims resolved by the settlement are only allegations. There has been no determination of liability. It is interesting to note that both doctors appear to still be in business. (Let’s hope these two have seen the error of their ways and can put their illegal billing practices behind them.)

Today’s Fraud of the Day comes from a Department of Justice press release, “Court assesses more than $170M in penalties against two area ophthalmologists,” dated November 18, 2021.

A man and woman who took part in a scheme to use prison inmates’ personal information to fraudulently obtain unemployment benefits were sentenced Monday to state prison terms.

Ryan Kubista and Maereichelle Marquez, both 34, pleaded guilty last month to felony charges of making false statements on an unemployment application, about six months after the San Diego County District Attorney’s Office announced charges against them

 

 

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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.