Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

March 26: Week That Was in Healthcare Fraud and Malpractice

By Jacqueline DiChiara

- Here is a general roundup of the past week’s developments in healthcare fraud and malpractice, as reported by the Department of Justice. The crimes reported below result in multiple millions of dollars in healthcare fraud and the possibility of extensive prison time.

Husband and wife buy pills from patients in sham clinic

Mario Fuertes and his wife, Gladys Fuertes, of Miami, were found guilty by a federal jury this week for a conspiracy involving healthcare fraud and obstructing a healthcare investigation.

The Fuerteses established and operated a sham clinic, Gables Medical and Therapy Center (Gables), for the purpose of committing healthcare fraud.

They face a maximum of ten years in federal prison on a conspiracy count, each of ten healthcare fraud counts, and up to five years in federal prison on each of two obstruction counts.

G. Fuertes was also convicted of four counts of aggravated identity theft and faces a mandatory sentence of two years in prison.

M. Fuertes and G. Fuertes employed unlicensed medical professionals and misused the Medicare billing numbers of other unknowing medical professional to claim rendered medical treatments.

The Fuerteses fraudulently billed Universal’s Medicare Part C and Part D plans over $900,000 for items including expensive HIV-related treatments that patients did not actually receive. Additionally, bills for services required a physician’s presence when no licensed physician was present to render services.

The Fuerteses also forged signatures for fraudulent patient prescriptions for a variety of controlled substances, including oxycodone.

A co-conspirator purchased pills from patients and then sold them on the street, reports confirm.

The Fuerteses instructed patients to lie once the federal healthcare investigation commenced. They also altered Medical billing documentation.

NJ doctor fails to report $1M income on tax return

Yash Khanna, a doctor practicing family medicine in New Jersey, was sentenced this week to nine months in prison for failing to file tax returns on nearly $1 million in income acquired over three years. Khanna also received kickbacks for diagnostic testing referrals.

Khanna, who owned and operated Family Medicine Pediatrics LLC in East Orange, New Jersey, admitted to collecting envelopes containing cash kickbacks.

Khanna additionally admitted to earning income of more than $381,000 in 2008, $400,000 in 2009, and $214,000 in 2010 and intentionally failing to file tax returns or ask for extensions during this time period.

In addition to the nine months of prison time, Khanna was fined $30,000 and ordered to forfeit over $10,000. He was also sentenced to one month of house arrest and three years of supervised release.

Michigan hospital pays $4M for false Medicare claims

Portgage Hospital, LLC, in Hancock Michigan, will pay over 4 million dollars for violating the False Claims Act for submitting false claims to Medicare for home healthcare services allegedly rendered by a staff physical therapist.

Via settlement from a self-disclosure with the US Department of Health and Human Services, Office of Inspector General (HHS-OIG), it was determined physical therapy services the staff therapist provided to Medicare home healthcare patients between 2006 and 2013 were medically unnecessary, lacked sufficient documentation of medical necessity, and did not qualify for payment via Medicare.

Although between 1,800 and 3,300 home healthcare visits were allegedly performed, documentation from the staff therapist failed to establish patients’ homebound status and the need for skilled therapy services.



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