Any test which doctors provide themselves (self-referral) is an opportunity for fraud. To identify suspect cases, measure the number of tests per 1,000 patients for doctors performing the test themselves, compared to those who refer patients to another provider. You may need to make adjustments for patient diagnosis or health status.
Of course looking to evidence is most important. Are these doctors qualified to perform the service? Is the diagnostic test effective as a screening tool or should its uses be more limited? Does the test result in more treatment? Is the treatment effective?
Here are some highlights from an article from the New York Times about a product with high fraud potential:
United States Attorney
Southern District of New York
FOR IMMEDIATE RELEASE
DECEMBER 6, 2005
UNITED STATES INTERVENES IN FALSE CLAIMS ACT LAWSUIT
AGAINST CABRINI MEDICAL CENTER ALLEGING ILLEGAL
MEDICAID PATIENT REFERRAL SCHEME
MICHAEL J. GARCIA, the United States Attorney for the Southern District of New York, announced today that on December 2, 2005, the Government filed a civil complaint against CABRINI MEDICAL CENTER (“CABRINI”). The complaint alleges that CABRINI entered into an illegal patient referral scheme with APPLIED CONSULTING, INC. (“CONSULTING”), and then falsely billed Medicaid for the care of these illegally-referred patients. CABRINI also allegedly billed Medicaid for alcohol and substance abuse detoxification treatment that it was not certified to provide.
Press Release: US Dept of Justice, US Attorney, Southern District of Texas, Chuck Rosenberg
November 17, 2005
Public Affairs Specialist
P. O. Box 61129 Houston, TX 77208
Phone: 713/567-9388 Fax: 713/718-3389
(HOUSTON, TX) United States Attorney Chuck Rosenberg today announced the verdicts of a federal jury convicting Dr. Anant Mauskar, 72, of conspiracy to commit health care fraud and receiving kickbacks as a result of a scheme that cost Medicare and Medicaid health care benefit programs millions of dollars in losses due to fraudulent claims. Charged with a total of 24 counts of health care fraud in connection with Medicare and Medicaid claims for physical therapy services and durable medical equipment, Mauskar was convicted of 20 of those counts and acquitted of four.
Adam Stupak, pleaded guilty on December 21, 2004 to offering three New York City doctors free trips to France if they agreed to write 30 new prescriptions for Serostim in one week. The illegal promotion was part of Serono’s “$6m-6 Day Plan” to increase demand for Serostim, an expensive drug used in the treatment of AIDS wasting.
A press release by the US Attorney in Boston describes the situation at Serono that prompted the promotion. Serostim, a growth hormone, was approved by the FDA in 1996 for the treatment of involuntary weight loss in patients with AIDS, which at the time was the leading cause of death among AIDS patients. Protease inhibitors came on the market at the same time as Serostim (generic somatropin). Protease inhibitors were so successful at controlling AIDS and preventing symptoms, that the market for Serostim started to dwindle.
The settlement resolves civil liabilities from alleged kickbacks paid to physicians, false statements made to obtain payment for unnecessary services, and payments made to Gambro Supply, a sham DME company.
November 15, 2004, Boston. Dr. John Romano, a urologist in Massachusetts pleaded guilty to fraud for charging Medicare and Medicaid for free samples of Lupron. Sentencing is scheduled for February 2005.
According to the US Attorney’s Office in Massachusetts, four other urologists have been sentenced in connection with this investigation. Dr. Joseph Olstein (Maine), Dr. Rodney Mannion (Indiana), Dr. Jacob Zamstein (Connecticut), and Dr. Joseph Spinella (Connecticut) pleaded guilty healthcare fraud. These doctors were sentenced to probation, in exchange for their help with the Lupron investigation, which resulted in a $1.2 million settlement from TAP Pharmaceutical.
Dr. Joseph Olstein helped the government get a $1.2 billion settlement from TAP Pharmaceutical and AstraZeneca. In return he received only a light sentence for his part in the scam. The US Attorney announced that Olstein was sentenced this week to one year probation and a $20,000 fine (in addition to a previous $50,000 restitution payment).
Dr. Olstein pleaded guilty in 2001 to billing insurance companies for free samples of Lupron, which he received from TAP sales people. Lupron is an injectible drug used for treating prostate cancer. Physicians can bill Medicare and other insurers for injectible drugs. Because the free samples were given as a way for physicians to enhance their income, the samples are considered a kick-back. Without the kickbacks that TAP offered to urologists, an equivalent drug that is cheaper than Lupron would probably have been prescribed.
“It’s all about the money,” was the operating creed of Hatch Dental, as described in a 42-count felony complaint filed by California Attorney General Bill Lockyer on September 22, 2004. The complaint describes how 20 defendants affiliated with three Hatch Dental clinics let greed rule their practice at the expense of patient health and safety.
In spring of 2002, when Brian Kanarek, DDS asked defendant Kyon Maung Teo (the alleged ringleader) why he over-diagnosed treatment, Teo told him, “Something has to pay for this practice.” After Kanarek diagnosed only 2 fillings for a patient whom Teo diagnosed 26, Teo told him to leave Hatch Dental “and don’t come back.”