Provider Beware: Healthcare Scam Warning Signs

Nearly every day, stories appear about healthcare professionals who get caught up in fraudulent activity. From billing for medically unnecessary services or for services never rendered, to accepting kickbacks for patient referrals, there is an unending stream of healthcare fraud taking place.

Often, those perpetrating the crimes are well aware that their activity is, at the most illegal, or at the very least, questionable and suspect. However, there are some healthcare professionals who, through no fault of their own, other than ignorance, find themselves on the wrong side of the law. Such was the case with a doctor the firm represented whose Medicaid provider number was used without his knowledge to fraudulently bill Medicaid.

Dr. Jose Gomez Cortes worked for multiple clinics. Unbeknownst to him, his Medicaid provider number, credentials, and email were fraudulently used by the owner of a clinic to bill Medicaid. The clinic’s owner, Lourdes Haber, is now a fugitive and is charged with related fraudulent conduct for using five other physicians’ Medicaid numbers.

Because of Haber’s fraudulent billing, the Agency for Healthcare Administration (AHCA), which oversees the Florida Medicaid program, assessed an overpayment against Dr. Gomez Cortes. AHCA also mailed the clinic notice advising the doctor that unless the funds were repaid, AHCA would take action against his Medicaid provider number.

The clinic owner created a false email address under Dr. Gomez-Cortes’ name and changed his practice location with Medicaid to disguise her criminal conduct.  As a result, Dr. Gomez Cortes never received a notice of an overpayment or signed the overpayment repayment plan. Haber not only withheld these notices, but also forged his signature on the repayment plan with Medicaid. Haber never repaid Medicaid. Due to non-payment, the doctor’s Medicaid number was terminated for cause, his Medicare provider number was terminated, and the Florida Board of Medicine filed an administrative complaint against his medical license for having his Medicaid provider number terminated.

It’s important to note that there are numerous collateral consequences to the provider licensee based upon a Medicaid termination with cause including the following:

  • The provider loses the ability to bill Medicaid;
  • The termination will be reported to Medicare, which will result in being terminated from the Medicare program;
  • The termination will be reported to the Department of Health licensure board and the department likely will not renew the professional license.

If terminated with cause from the Medicare program, the following may occur:

  • Lose your ability to bill Medicare.
  • The termination will be reported to Medicaid, which will result in a Medicaid Provider Agreement termination.
  • You and the entity may be placed on the OIG exclusion list.
  • When placed on OIG exclusion list, you likely will be reported to the Department of Health Board and the department will not renew the professional license.
  • Terminations will result in reporting obligations to health care data banks (NPDB) and third-party payers, which may result in cancellation of provider contracts.

Dr. Gomez Cortes never received a notice of the overpayment, Medicaid termination and the Board of Medicine Administrative complaint. It was only after Dr. Gomez Cortes learned that Haber had fled the country, and that his medical license was not going to be renewed due to being terminated for cause from the Medicaid program, that he retained the Health Law Offices of Anthony C. Vitale to investigate and challenge the Medicaid termination and the administrative complaint.

After great expense, time, and litigation, the AHCA Final Order of terminating and Medicaid overpayment was vacated and Dr. Gomez Cortes’ Medicaid number was restored. Additionally, the Florida Board of Medicine rescinded the administrative complaint filed against the doctor’s medical license.

This client wasn’t the first, and sadly will not be the last, to unwittingly become entangled in a healthcare fraud scheme that could have cost him his livelihood.

Doctors, particularly those who are young and looking to build a practice, or those who are looking to supplement their existing income, are targets for those who engage in healthcare fraud.

It sometimes looks like this: The doctor is contacted by a clinic, telemedicine company or similar type provider, looking for physician, “medical director” to review patient charts to “oversee” a physician assistant or ARNP. The “credentialing” process is quick and easy and all the provider has to do is sign off on orders without ever seeing the patient. The jobs also might be posted on Craigslist, Monster.com or a similar site. The healthcare professional signs up, opens a business account and the money starts to flow in, sometimes even before signing off on the first patient.

We stumbled upon a forum where doctors were discussing opportunities and one read as follows: “I recently started doing some moonlighting for a couple telemedicine companies. The practice so far has been ordering DME (knee, ankle, lumbar braces etc.).  My instincts kicked in after about 5 charts and I started to feel like these were scams. The physician notes were entirely pre-populated. In fact, there is only a small space to document any of my semi-required phone call to the patients.”  He went on to note that “Some patients with whom I’ve spoken have some legitimate pain issues. Seems like others have been solicited for a free brace and just say ‘why not?’”

Bottom line: If you think it sounds too good to be true, it probably is? If you are told you don’t need to see patients and just sign off on medical charts, it’s probably a good idea to contact an attorney immediately.

The minute a healthcare provider becomes aware of a fraud or licensure investigation is when the assistance of an experienced healthcare attorney is required. The firm represents clients during all stages of investigations and can advise you before you become involved in a questionable relationship.

If you have any questions, contact us at 305-358-4500 or send us an email to info@vitalehealthlaw.com.

Material presented on the Health Law Offices of Anthony C. Vitale's website is intended for information purposes only.

It is not intended as professional advice and should not be construed as such.