The Department of Justice (DOJ) recently announced criminal charges against a New York ophthalmologist. In this case, the prosecution claims a physician fraudulently billed Medicare and private insurance companies for procedures that patients never received. According to the indictment, the ophthalmologist allegedly made these fraudulent charges from 2010 through 2017.
The government went into details within the indictment, using the example of billing for a chalazion procedure to elaborate on the charges. This procedure essentially entails the removal of a mass on the eyelid. According to the prosecution, this procedure should result in a bill to insurance of approximately $200. However, the prosecution claims that this ophthalmologist charged the procedure as a complex ophthalmological surgery, leading to an average bill of $1,400.
Additional allegations include:
- Upcoding. Not only is the physician accused of upcoding or listing the procedure as a more expensive one then it actually was, he is also accused of requiring his employees to up code on his behalf.
- Debt collection. The DOJ has also stated the physician pursued debt collection options to get payment from patients who refuse to pay the allegedly fraudulent bills.
- Falsification of patient records. Manhattan’s U.S. Attorney also states the doctor altered patient records to help justify his fraudulent claims.
Ultimately, the government has accused the physician of over $8 million in fraudulent billing. He faces both criminal and civil prosecution. Criminal charges include health care fraud, wire fraud and false statements relating to health care matters. If convicted of all charges, he could face up to 35 years imprisonment, monetary fines and mandatory restitution payments. A successful civil claim could result in additional monetary penalties.
This case provides an example of the serious penalties that can result from allegations of health care fraud. Those who are the subject of such investigations can seek legal counsel to represent their interests and better ensure a more favorable outcome.