The Doctor Who Avoided Healthcare Fraud Conviction

The Doctor Who Avoided Healthcare Fraud Conviction

You know how sometimes you hear a news story that just makes you shake your head and wonder “how did they get away with that for so long?” Well, that’s exactly what I thought when I read about this doctor who managed to avoid a healthcare fraud conviction despite being involved in a huge Medicare scam.

Now, I don’t want to jump to conclusions here – innocent until proven guilty and all that – but the details of this case are pretty wild. Let’s break it down:

The Scheme

According to the Department of Justice (DOJ)[1], this doctor was involved in a scheme to defraud Medicare out of over $200 million dollars! Apparently there were some telemarketing companies that would call up Medicare beneficiaries and convince them to request expensive orthotic braces and genetic tests. Then they’d send the pre-filled out order forms over to this doctor, who would just sign them without ever even speaking to most of the patients.

I mean, that is pretty blatant fraud right there. This doctor was basically just rubber stamping forms for braces and tests that the patients didn’t even want or need. And we’re talking thousands of forms here, resulting in over $200 million in false Medicare billings. Yikes.

The Trial

So with a scheme this big, you’d think it would be a slam dunk case, right? Well, apparently not. This doctor was actually acquitted on most of the charges against her.

She went to trial in Miami and was facing one count of conspiracy to commit healthcare fraud and wire fraud, plus four counts of actual healthcare fraud[2]. And the jury did convict her on that conspiracy charge.

But they found her not guilty on the other substantive healthcare fraud charges.

I’m scratching my head over here wondering how she got off on those. I mean, the DOJ said she signed off on thousands of unnecessary genetic tests and braces without examining patients. That seems like pretty clear healthcare fraud to me.

Why She Wasn’t Convicted

After doing some digging, it seems like the reason she avoided the fraud convictions comes down to two things:

1. Blaming the Telemarketers

The doctor’s defense was that she thought the telemarketing companies had actually spoken to the patients and verified they needed the braces and tests before sending her the forms.

She claimed she didn’t realize the companies were just sending her pre-filled out forms for services patients didn’t want. So she argued that it was the telemarketers who were really to blame for the fraud[3].

2. Sloppy Medicare Oversight

The other issue is that Medicare’s oversight of genetic testing claims was very lax at the time. There were no limits on how many tests a patient could receive, so ordering excessive, unnecessary tests wasn’t necessarily against the rules[4].

So while the doctor’s actions were unethical, prosecutors had a hard time proving they were actually illegal healthcare fraud under the letter of the law at the time.

What This Means

While it’s disappointing this doctor wasn’t held fully accountable, this case does highlight some important issues:

• Doctors need to verify medical necessity themselves, not just trust outside companies
• Medicare has to improve oversight of claims for braces, genetic testing, and other equipment
• Telemarketers preying on seniors for unnecessary medical equipment should face consequences

The government did get a conspiracy conviction, so that’s something. But the fact that this doctor got off on the major fraud charges shows there’s still work to be done when it comes to prosecuting these kinds of healthcare scams.

Could This Happen Again?

The question is – could a doctor get away with avoiding fraud convictions like this again today?

Well, maybe. But there have been some changes that would make it harder:

• Medicare has cracked down on genetic testing oversight since this case happened[5]. There are now limits on how many tests can be ordered and documentation is required showing they are medically necessary. That takes away the “sloppy oversight” defense.
• The DOJ is focused more on prosecuting healthcare fraud. There are strike forces dedicated to charging these cases[1]. So doctors involved in scams may face more scrutiny.
• Whistleblower rewards may make insiders more likely to report fraud. There have been some hefty rewards paid out for reporting Medicare fraud schemes. That makes it riskier for doctors to participate.

So in summary – yes, it’s still possible a doctor could avoid conviction for healthcare fraud. But hopefully lessons learned from this case will make it less likely crooked schemes can operate unchecked in the future.

What do you think? Should doctors involved in fraud face stiffer penalties? Or did this one just slip through the cracks thanks to messy oversight and telemarketer tricks? I’d love to hear your thoughts!