Scams related to healthcare services by unlicensed individuals highlight not only fraud-related financial loss but also patient safety risks. Cases presenting this combination of issues should be a top priority for investigators, as Deloitte's Mike Little told FierceHealthPayer: Anti-Fraud in an exclusive interview.
Consider the case of Connecticut's Francisco R. Carbone, M.D. His medical license was revoked almost 10 years ago, but he subsequently managed to cheat health insurers out of more than $1.7 million, The Courant reported.
Carbone used an osteopath to prescribe pain medicine for patients. He provided medically unnecessary care, claimed payment for services not performed and exaggerated the extent of patients' injuries to qualify for payment, the article noted. Carbone accepted referrals from a lawyer who recruited patients by illegally paying runners for ambulance chasing, rounding up clients who had fender-benders for follow-up healthcare, The Courant noted.
Meanwhile, Florida podiatrist James F. Pruchniewski, D.P.M., pleaded guilty to healthcare fraud after coding Medicare claims as physical therapy when the services provided were noncovered micro-vas treatments, according to The Ledger. Beneficiaries received these from an unlicensed staffer who applied pads and wire leads, turned on electric current and adjusted the machine's dial for pain tolerance, the article stated.
These issues echo the case of Miami's Christopher Gregory Wayne, D.O., who was sent to prison for fraud involving performance of physical therapy by unlicensed "office girls." And in Atlanta, obstetrician/gynecologist Nathaniel Johnson, M.D., pleaded guilty to defrauding Medicaid and aiding in the unlicensed practice of medicine, according to The Atlanta Journal-Constitution.
Johnson employed Jeff Romeus, a graduate of the American International School of Medicine in Guyana, as a doctor despite knowing he wasn't licensed to practice medicine, the AJC noted. Nevertheless, Romeus examined patients, prescribed drugs and supervised medical students in Johnson's absence. Romeus treated nearly all the patients in the practice. More than 75 percent of Johnson's billings were fraudulent, investigators found.