It seems that every week, I come across another press release from the OIG (Office of Inspector General) announcing that a healthcare provider has been convicted of Medicare fraud.
The OIG for the Department of Health and Human Services (HHS), along with a host of other agencies, investigates fraud in healthcare.
For years, I have been a subscriber to the OIG list, and it’s always sobering and sad to hear of healthcare providers who are involved in healthcare fraud.
But what hits me the hardest is when I see a fellow Nurse Practitioner on that list, especially when it’s someone I know.
Recently, I read about an NP I once consulted with. She’s a smart and capable individual with lots of potential who is now facing serious legal consequences for her actions.
Unfortunately, she isn’t the only one I’ve known personally to fall into this trap.
Unsurprisingly, the physician who “inspired” me to start my first practice ended up being convicted on multiple counts of fraud, among other charges.
His career ended with a 17-year jail sentence. All four of his offices were abruptly shut down, leaving countless patients and employees hanging.
This Begs the Question…
How do otherwise intelligent and usually well-intentioned professionals end up in career-ending situations?
Could it be anything else besides the temptation of easy money?
Healthcare fraud is big business…
In the majority of cases, it’s not the providers committing the fraud initially, but other parties.
For providers who do get involved in fraudulent activities, I can see that for some, it may start completely innocently.
Someone promises “easy money” in exchange for a signature… on genetic testing orders, drug screenings, or durable medical equipment (DME) prescriptions.
And casually, they’re being told of other providers who’re also working with the company… that’s social proof.
“It’s all legal, all above board,” they assure with authority. “You’re just signing off on what your patients need anyway.” … speaking with an air of authority, they convince providers that it is alright.
And for a moment, the all-too-tempted provider thinks…
“The company has done this for all while, so it must be alright. Surely, they know what they are doing. All the other providers wouldn’t work with them if it weren’t above board, right?”
One would think…
But what they don’t tell you is that these arrangements often cross into fraudulent territory.
And when the OIG begins to investigate (and they will), it’s your name and license on the line. Essentially, you’re the one left holding the bag.
Common Types of Fraud the OIG Investigates:
Based on recent OIG reports, here are some of the most common schemes duping providers, which is not to say that the participating provider shares no responsibility.
Genetic Testing Fraud:
Companies target providers to order unnecessary or non-medically indicated genetic tests, often billing Medicare thousands of dollars for each test.
Drug Testing Abuse:
Some clinics bill for expensive drug screening panels that patients don’t need, with providers’ signatures serving as the “justification.”
DME (Durable Medical Equipment) Fraud:
This includes prescriptions for braces, wheelchairs, or orthotic devices that patients never requested or didn’t medically require.
Telemedicine Scams:
Here, providers are paid to “approve” medical equipment or prescriptions after a very brief, or even nonexistent, telehealth visit.
Upcoding or False Billing:
Fraudulently submitting claims for services never rendered or billing for a higher level of service than what was provided.
Each of these schemes might start small… with a simple signature or a quick telehealth approval.
Still, the consequences for the provider can be devastating, including loss of licensure, hefty fines, criminal charges, and even prison time.
The Reality…
The hard truth is that even smart people can fall into these traps, especially when the scheme is presented as a legitimate business opportunity.
It’s easy to assume, “if everyone is doing it, it must be fine, it must be legit.”
No, it is not! Just because everyone drives above the speed limit doesn’t mean speeding is legal.
But when OIG investigators follow the money, they rarely go after the companies that started it. Instead, right or wrong, they go after the providers whose names appear on the paperwork.
The Moral of the Story…
I don’t share this to point fingers, but as a warning.
If something sounds too good to be true, it probably is. Your license, your career, and your reputation are worth far more than a quick payday.
It’s your responsibility to stay informed and ask questions. Remain an independent and critical thinker.
And if a business opportunity involving Medicare or Medicaid billing feels too good to be true, it probably is “too easy.”
Listen to your gut…
Walk away…
The risks are far greater than any reward could ever be.
Instead, focus on generating more revenue using legit strategies; there are many ways to do it.
Have you been approached by a third party offering dubious business opportunities before? Please share your experience with your colleagues so we all can learn…
By Johanna Hofmann, MBA, MAc., EAMP; regular contributor to the NPBusiness blog.