By Sonal Patel BA, CPMA, CPC, CMC, ICDCM SP Collaborative |
Monthly Spotlight on Fraud, Waste, and Abuse


Monthly Spotlight on Fraud, Waste, and Abuse

Date Posted: Tuesday, August 29, 2023


The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services. 

United States Files a Lawsuit Against a Radiologist for Allegedly Performing Unnecessary Peripheral Artery Procedures

In its complaint, the United States alleged that the interventional radiologist, his practices, and his management entities billed Medicare and the Federal Employees' Health Benefits Program for medically unnecessary invasive peripheral artery procedures in patients' legs between at least January 1, 2016, and December 31, 2019.
The complaint also alleges that they were reimbursed at least $6.5 million dollars for over 500 claims.

The allegations regarding unnecessary vascular procedures are described in detail in the complaint and include unnecessary angioplasty, atherectomy, and the placement of stents, as well as the indiscriminate use of intravenous ultrasound. Each procedure requires puncturing the skin and inserting devices into and through the arteries in patients' legs. As the relevant standards of care indicate, unnecessary invasive vascular procedures may cause harm to patients' health, including increasing their likelihood of needing future procedures, and putting them at greater risk of leg amputations.

As alleged, the parties knew from prior administrative sanctioning that unnecessary procedures are contrary to standards of care and federal law. 

The interventional radiologist was previously sanctioned in other states' medical boards and Medicaid programs for improperly performing unnecessary, experimental vascular procedures, including angioplasty and stenting. These procedures were performed on hundreds of patients for the purported treatment of multiple sclerosis, a non-vascular disease.

All civil claims in this case are allegations only. There has been no determination of civil liability.

Read the specifics of this case at www.justice.gov.

United States Files Complaint Alleging Iowa Surgeon Caused Submission of False Claims to Medicare 

The complaint alleges that from approximately August 2014 to August 2019, this plastic surgeon submitted or caused to be submitted false claims for healthcare services to government payors, including Medicare. The complaint alleges that the plastic surgeon: (1) billed government payors for services he claimed were medically necessary surgical procedures, but were in actuality medically unnecessary cosmetic surgeries, which are not payable by government payors; (2) billed for services in excess of those actually rendered (upcoding) to increase reimbursement, or even billed for surgical procedures he didn't perform at all; and (3) overstated the complexity of office visits with patients in order to obtain greater reimbursement from government payors.

Read more about this case at www.justice.gov.

Court Enters $487 Million Judgment Against Precision Lens and Owner for Paying Kickbacks to Doctors in Violation of the False Claims Act

A jury found that almost 65,000 false claims were submitted to Medicare, which resulted in over $43 million in damages to Medicare.

As proven at trial, a leading ophthalmic surgical distributor provided kickbacks to ophthalmic physicians and surgeons in various forms, including travel and entertainment. Multiple examples of trips were identified, including high-end skiing, fishing, golfing, hunting, sporting, and entertainment vacations, often at exclusive destinations. For many of the trips, the distributor transported these physicians to luxury vacation destinations on private jets. These included trips to New York City to see a Broadway musical, the College Football National Championship Game in Miami, Florida, and the Masters golf tournament in Augusta, Georgia. The distributor also sold frequent flyer miles to their physician customers at a significant discount, enabling the physicians to take personal and business trips at well below fair market value.

A Deputy Civil Chief for the United States Attorney's Office on the case stated, "Medicare beneficiaries are entitled to know with certainty that their physician's decision-making has not been compromised by a private flight, expensive ski-trip, or any other unlawful inducement. This office is committed to investigating misconduct and recovering funds unlawfully obtained from federal healthcare programs."

Read additional details of this case at www.justice.gov.

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is the CEO and Principal Strategist for SP Collaborative, serving as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical codes, auditors, and compliance professionals to elevate coding compliance education for the business of medicine.

Search BCA Magazine

Search here

List Articles

Select below

Editorial Board



CEO & Principal Strategist
SP Collaborative





Search BCA Magazine

Search here

List Articles

Select below