Physiatrist Joseph A. Raia, M.D. agreed to repay $1.5 million in assessments and civil monetary penalties (CMP) and accept a 15-year exclusion from federal healthcare programs to settle allegations of defrauding Medicare, the Office of Inspector General announced last Wednesday.
The OIG claimed Raia filed thousands of Medicare claims between 2006 and 2011 for physical therapy and rehabilitative services that were never done or were otherwise false or fraudulent. Specifically, Raia wasn't present when claimed services supposedly occurred, and he billed for care simultaneously rendered in five settings in two states, the announcement stated.
The OIG also alleged Raia used chiropractors inappropriately to provide physical therapy "incident to" his professional services, and that Raia often billed for time-based procedures exceeding 24 hours daily. Raia is licensed in New York and New Jersey.
Settlement of this case comes amid efforts to expand the OIG's CMP authority to implement Affordable Care Act statutes. If approved, two proposed rule changes would streamline the CMP process and add to the list of situations in which the government can wield CMP authority, according to a recent commentary by former HHS Inspector General Richard P. Kusserow.
Proposed changes would provide an intermediate sanction for many fraud and abuse provider problems where enforcement today is difficult, Kusserow noted, such as noncompliance with record requests or failure to grant timely access to the OIG. Proposed changes also would empower the agency to penalize providers for conduct not adequately addressed under current regulations, Kusserow wrote, such as excluded practitioners who keep prescribing drugs.
Overall, "decertifying a provider is like using a nuclear option," Kusserow wrote. "Granting the OIG authority to penalize uncooperating providers with financial penalties would give added teeth to their enforcement powers."