Posted and filed under Fraud, FWA, Healthcare.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

For those of you who keep up with the latest and greatest in healthcare fraud (and I am sure everyone who is reading, or at least looking at this blog, keeps up with it), you may have seen the recent case involving a company named Portable Radiology Associates.  The investigation resulted in 25 charges of Healthcare Fraud and False Statements Involving Healthcare programs, and $2 million in fraudulent billing.  When I read that the fraud involved the forging of signatures on reports and billing for deceased patients, it led me to the same statement I made in last week’s blog: “if it doesn’t cost me anything, why should I care?”  Anyone who knows the Managing Director of Advize Health, Jeanmarie Loria, knows that she is a huge proponent of patient involvement in the lifecycle of a claim, and the payment that is generated from the service.

When I was at the OIG, I investigated a very similar matter; a husband and wife that operated a mobile diagnostic company billing for services that involved false interpretations and forged signatures of reading physicians.  The husband, a certified radiology technician, paid, as many do, rent in return for using space in predominately internal and primary care physician offices.  The primary care providers would refer their patients to the technician, who would perform a variety or ultrasound, cardiac and neurological tests on the patients, pursuant to a written order for the tests.  The problem, however, was the certified technician chose to take a shortcut, and instead of sending the test results and images to a radiologist, neurologist or cardiologist (depending on the test), the technician made the conscious decision to create the interpretations himself.  He and his wife, who ran the office, would then affix a photocopied or “cut and paste” of an actual radiologist, neurologist or cardiologist signature, to make it appear as though the test was interpreted, and the report prepared by the reading physician.

If it doesn’t cost me anything, why should I care?

By the way, the Medicare reimbursement for the interpretation and report was approximately $30, and the agreements with the reading physicians they had was for about $20 per study (yes, they actually had agreements, but they just never used the reading providers to pocket the $30 and get reports to referring providers faster).  And of course, copays were likely not collected in many instances, so it did not cost the patient anything additional.  The reports had no medical value, since the reports were created by the technician, sometimes dictating the language for the report to an office worker, via telephone, while the technician was out of the country.  In all, thousands of tests were performed that were fraudulent.  I had the great pleasure of reviewing (with the help of an amazing intern) each and every report I was able to obtain, and compared the signatures, along with other documents, to identify the legitimacy of the reports.  The husband and wife subsequently pleaded guilty and were sentenced to lengthy prison sentences (the husband received 100 months and the wife 84 months).  They had to pay back millions of dollars to Medicare and commercial insurance plans and were excluded from government program participation.

So, what does this have to do with the premise of “if it doesn’t cost me anything, why should I care?”  During the course of the investigation, each referring physician that was identified was contacted.  Each referring provider received a letter outlining the issue discovered, that the reports were likely unusable in the care and treatment of the patient, and each referring provider was given a list of identified patients that were potentially affected.  It did not appear that in any of the instances where the referring provider was notified of the issue, did the referring provider retest or otherwise determine if the false test results had a negative impact on the care of the patient.  In many instances, important cardiac related tests were performed, as well as studies to identify potential blood clots in legs, arms and arteries.  I suppose if the referring provider didn’t care, why would the patient?

As a related aside, it was also discovered that the husband and wife had, at least with one provider, paid the referring provider’s home property taxes, commercial property taxes, and for the remodeling of the referring provider’s kitchen.  In at least two other instances, the husband and wife had the referring providers submit the claims for the services using the referring provider’s NPI numbers, as the husband and wife did not have an NPI in the state where the services were being rendered.  The husband and wife, of course, submitted the commercial claims, as out of network—because why wouldn’t you want to submit for the claims that will pay the highest amount, and leave the Medicare payments to the referring provider?  I guess that answers the question; “If it doesn’t cost me anything, why should I care?”