Medicare Fraud

Every year, we lose billions of dollars to fraud in federal and state health care programs. Every dollar we lose to fraud and abuse is a dollar that is not available to provide home care to seniors, to treat HIV and AIDS, to immunize children, and to discover new treatments for cancer and other diseases. Some fraud schemes even pose a direct threat to the health and safety of patients. Many instances of health care fraud sug­gest that existing control systems do not work the way we imagine they should. Often the manner in which schemes are revealed suggests detection is more luck than system. Whistleblower lawsuits have exposed billing by health care providers for services not rendered, billing for products not delivered, misrepresenting services, unbundling services, billing for medically unnecessary services, duplicate billing, increasing units of service which are subject to a payment rate, falsifying cost reports resulting in increased payment to the health care provider, kickbacks, and on and on. Healthcare fraud is still going strong and this blog is intended to keep readers up to date with all healthcare fraud related news and to provide commentary when warranted. This blog also contains an array of laws and regulations concerning healthcare fraud set out in an easy to read format.

Two Chicago Cardiologists Charged With Medicare Fraud

by Nolan and Auerbach on February 10, 2009

Chicago, Illinois—  Cardiologist Sughil Sheth received $13.4 million over a period of five years (2002-2007) by billing Medicare for reimbursement of extensive cardiac care that was not, according to U.S. Attorney Patrick Fitzgerald, ever performed.  Sheth allegedly performed Medicare Fraud by hiring individuals to falsify patient names, insurance data, and dates in order to bill $8.3 million to Medicare and $5.1 million to other insurers.

In the second case,  general practitioner Otto Garcia Montenegro was charged with healthcare fraud—for using his Chicago-area clinic to submit false claims over a period of four years (2003-2007). Rather than collecting co-pays and deductibles from his patients in accordance with the standard procedure, Montenegro submitted hundreds of claims to insurers for treatments that were never performed.  As a result, he collected nearly $900,000 in payment from health care insurers and exhausted patient deductibles in the process.

Regarding their cases, United States Attorney Patrick Fitzgerald said: “Healthcare fraud remains an important priority of federal law enforcement. We will use all of our resources to ensure that dishonest physicians and other medical providers do not profit from cheating Medicare and private insurers.”

While this announcement involved criminal indictments, it is likely that prosecutions under the federal False Claims Act will follow.

To read the full press release, go here.

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