Posted and filed under Compliance, Fraud, FWA.

The Fraud Spotlight series is a long-form examination of current fraud trends and investigative strategies from our team of retired OIG agents and expert fraud investigators. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

In the past few weeks, there have been some notable prosecutions concerning the on-going frauds associated with COVID 19. As the frauds begin to make themselves known, we in the fraud, waste, and abuse (FWA) world are gaining clarity as to what the schemes will look like. More importantly, we are also seeing how fraud schemes, and the unscrupulous providers, are capitalizing on the ability to transcend their frauds to other well-intentioned programs. Such is the case with Dr. Ameet Goyal.

Goyal, an ophthalmologist practicing in Rye, NY, was previously indicted for healthcare fraud. Rye, NY, is a small, bedroom community, north of NYC. While working as an IG Agent, I investigated a handful of ophthalmology cases, the most prominent being that of Dr. Carl Fromer, from Staten Island, NY. At the time, it was the largest healthcare fraud case in the Eastern District of NY ($9 million in total). Fromer was billing for a variety of medically unnecessary services, services not rendered, etc., most notably related to cataracts surgery and glaucoma. He was performing cataract surgery on patients that may not have had surgically implicated cataracts, and laser procedures on patients who may not have had glaucoma; a story for another day and getting back to Goyal.

Goyal, who is currently under indictment in the Southern District of NY, is prohibited from being able to receive funds from the Paycheck Protection Program (PPP). To receive these funds, the application requires an attestation that the applicant is not currently under any criminal charges. An indictment, unlike a criminal complaint, is a formal charging against the defendant. As such, Goyal is not eligible for the PPP money. However, according to publicly available documents, not once, but twice, Goyal purportedly sought, and obtained PP loans. He was able to receive the monies by falsely indicating in the negative that he was under any criminal charges. Of course, until either a trial and conviction or determination of not guilty, or a plea, these remain nothing more than allegations (as with the healthcare fraud charges as well, as those are still open charges). 

The point of my tale is that the difficulties that law enforcement will have in uncovering the cross COVID-19 frauds is going to be a talk that has never been undertaken. There are too many agencies that are involved, and too many programs to be able to succinctly and accurately check to see who got what, where and when. I strongly believe that we are going to see an explosion of task forces, coordination of information sharing and hopefully much increased prosecutions of those who took advantage of all the programs that were designed to have positive social implications during these unprecedented times. 

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact our former OIG and Fraud Investigation team by emailing info@advizehealth.com for more information on our Fraud Spotlight series.