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

Practice Management

Monthly Spotlight on Fraud, Waste, and Abuse

Date Posted: Tuesday, September 12, 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. 

Physician Sentenced for Stealing Approximately $250K From COVID-19 Relief Programs

A physician was sentenced to two and a half years in prison for fraudulently obtaining and misappropriating approximately $250,000 from two separate COVID-19 relief programs.

According to court documents, he was the supervisory physician at a medical clinic with three other offices in the state. From March through June 2020, he applied for and received government funds for COVID-19 relief from the Accelerated and Advance Payment Program and the Paycheck Protection Program. 

Both programs were designed to provide emergency financial assistance to medical providers and small businesses who were suffering economic effects from the COVID-19 pandemic. 

In total, he received approximately $250,000 from these programs and used the money to pay for his personal expenses.

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

Man Sentenced in a $134 Million COVID-19 Healthcare Fraud and Money Laundering Scheme

A man was sentenced to 15 years in prison followed by three years of supervised release and ordered to pay just shy of $30 million in restitution for conspiracy to commit healthcare fraud and money laundering.

He pleaded guilty to conspiracy to commit healthcare fraud and money laundering in 2022. According to court documents, he and his co-conspirators submitted more than $134 million in false and fraudulent claims to Medicare in connection with diagnostic laboratory testing, including urine drug testing and tests for respiratory illnesses during the COVID-19 pandemic, that were medically unnecessary, not ordered by medical providers, and not provided as represented. 

He and his co-conspirators obtained medical information and private personal information for Medicare beneficiaries, and then misused that confidential information to repeatedly submit claims to Medicare for diagnostic tests.
Read more about this case at www.justice.gov.

A Former Alaska Advanced Nurse Practitioner (APN) Sentenced to 30 Years for Illegally Prescribing Millions of Opioids Causing Five Deaths

An APN was sentenced to imprisonment for illegally prescribing and dispensing opioids outside the scope of legitimate medical practice that resulted in the deaths of five people between 2014 and 2019.

Evidence presented during the trial showed that she prescribed and dispensed 4.5 million dosages of opioids, including fentanyl, methadone, oxycodone, and hydromorphone, in just over five years. 

Many times, she combined the opioid prescriptions with prescriptions for other dangerous drugs, like valium and muscle relaxers, known as the "Holy Trinity," greatly increasing the chances of overdose death. 

She wrote these prescriptions with little to no medical justification or treatment plan; minimal, if any, tests or physical examinations; and little, if any, considerations of non-opioid treatment. 

Many of her patients were vulnerable and suffering from chronic pain, addiction, and mental illness, yet she disregarded their medical histories, risk factors, past overdoses, symptoms, and pleas to reduce or taper their doses. 

She also ignored warnings from patients’ family members, pharmacists, and other medical providers, and defied thousands of warning letters sent by insurance companies about the dangers of her practices.

An Assistant U.S. Attorney on the case stated, "This is the deadliest drug case in this district’s history. And disturbingly, the five deaths the Defendant was convicted of at trial are just the tip of the iceberg because [she] may have caused or contributed to the deaths of dozens: 20 total confirmed drug overdoses and many others suspected. She was a serial killer with a ‘poison pen.’" He added, "Her conduct was far more insidious" than that of a street level dealer "because she sanctioned (and supplied) lethal levels of drugs for her patients, day after day, year after year, under the shroud of a prescribing license, assuring them that it was safe and necessary. In the process, she abused her authority and violated her oath as a medical professional, prescribing higher doses per patient than any other prescriber in the state during the charging period."

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

ENT Doctor Sentenced to 25 Years in Prison for Adulterating Surgical Devices, for Defrauding Medicare, and for Stealing Patient Identities

An ENT doctor was sentenced to 25 years in prison for adulterating surgical devices used in more than 1,400 nasal surgeries performed on Medicare patients between 2011 and 2018. 

She was also ordered to serve three years of supervised release and ordered to forfeit $4.7 million. In January of this year, she was found guilty by a federal jury on 20 criminal counts, including device adulteration, fraud, conspiracy, and identity theft. 

Evidence presented at the trial demonstrated that she was an ear, nose, and throat (ENT) doctor who operated in multiple offices in the state.  She marketed balloon sinuplasty, an in-office procedure to treat chronic sinusitis, as a "sinus spa," and encouraged patients to come to the office for a "free" sinus spa, which was a treatment that they may not have needed.  

She falsified medical records to justify the billing of balloon sinuplasty surgeries to Medicare auditors.

Between 2011 and the end of 2017, she performed 1,555 balloon sinuplasty surgeries on 919 Medicare beneficiary patients, using the Food and Drug Administration (FDA)-approved Entellus XprESS device. However, instead of using the device only once and only on one patient, as required by FDA guidelines, she reused the devices on multiple patients. 

Between 2012 and 2017, she obtained, at most, 36 new Entellus devices, despite being, at times, the top-paid Medicare provider of balloon sinuplasty services in the country and providing more than 1,500 surgeries.  

In addition, she failed to inform her patients that they were receiving a procedure with an adulterated device.  During the trial, she admitted that she had sufficient money to buy every patient a new device but chose not to do so.

She billed Medicare for more than $46 million for the balloon sinuplasty procedures between 2014 and 2018.  In that time, she netted more than $4.79 million from Medicare for these surgeries.  That amount does not include any sinuplasty surgeries performed on patients with private healthcare insurance.  The jury at trial also returned an order that she forfeit the profits she obtained from private health insurance carriers.

A U.S. Attorney on the case stated, "Medicare auditors also found that she was the top biller for balloon sinuplasty surgeries in the country, having billed the program over $46 million.  When auditors began to audit the defendant’s practice, she and her staff falsified medical records and forged patient signatures in an attempt to justify billing the surgeries." The U.S. Attorney asserted, "This doctor put profit over patients by reusing single-use surgical devices hundreds of times, even though those devices came into contact with blood and other bodily fluids.  In doing so, she risked the contamination of one patient’s sinuses with the bodily fluids of other patients."

Read further information about 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.

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