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

From a resource perspective, we as a nation, and those in the law enforcement, public service, fraud, waste abuse, and you name an industry, are at a breaking point. From the fraud, waste, and abuse perspective, in particular, every day we see, read, discuss, and hear (to a point of saturation) about COVID-19 frauds that are here and coming.

The sad part is the road is paved with good intentions. Just recently, the State of New Jersey issued a temporary order allowing physicians licensed in their home country, but not licensed here in the US, to obtain a temporary and emergency license to assist in emergency care. This is going to undoubtedly going to be a double-edged sword. Although the thrust of what is sought in this order is meant to provide the current situation an infusion of help that is desperately needed, I am already thinking of all of the fraud that will come from it.

Unfortunately, just like many of you, we look at things from a different lens than others; the glass is often half-empty, even when it is overflowing.

We already know that the PECOS system is fraught with issues relative to verification and credentialing. Yes, there are going to be legitimate healthcare professionals who reside here in the US and are licensed from their home country where they will fit this need. What is stopping the unscrupulous individual from gathering the necessary bogus documents and then being off to the races? We saw that the fabrication and obtaining a Medicare Provider number from Marshall Allen’s Propublica article are real things. 

The state requirements for the temporary license are narrow, but the implications wide. Since these individuals will be in emergency-related situations, it then opens a host of questions about billing (as least for me). Will these providers’ services be billed to the Medicare and Medicaid and commercial programs? If so, what are the collateral issues from a regulatory perspective? Since there are numerous waivers in place (such 1135), will some, all or none of the waivers be implicated? What will the facility do to credential the providers, considering many of the credentialing requirements will not be able to be met. 

My head spun most of the weekend wanting to discuss and solicit opinions from many people I know. Of course, the first thing that became part of the discussion was “if someone is licensed in their country of origin, has a license in that home country, are in the US legally….” Why did they not obtain a license in the US? There are an equal number of potential responses; retirement and desire to reside here with family, inability to be fluent in English enough to pass the exams, costs associated with the process, etc. I am greatly interested in seeing if anyone steps into this role, how they managed, and really in the long term…did it lead to permanent licensure?

Strange times indeed. As always, stay safe, wash your hands, and if you can work from home and do virtual meetings: Try a mullet business outfit: dress shirt on top and those crusty house sweats on the bottom. And please, please, please: wash those dreaded house sweats; it has been too long.

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 Eric Rubenstein for more information on our Fraud Spotlight series.