Written By: Janie Ratliff-Sweeney

When you hear of Medicare fraud, you may think of billings for patients who never showed or for procedures that were never performed. What might not come to mind is a doctor performing unneeded invasive procedures or surgeries on patients to increase claims to Medicaid and Medicare billing. But that’s exactly what one Kentucky doctor was found to have done.

Anis Chalhoub, while a cardiologist at a London, KY hospital, allegedly performed multiple pacemaker implants over a four-year period. He was convicted of healthcare fraud and was sentenced to serve 42 months in prison and to pay more than $275,000 in restitution and $50,000 in fines. He has been prohibited from practicing cardiology for three years following his release from prison.

The brunt of the financial fallout landed on his former employer, Saint Joseph Health Systems (now KentuckyOne Health), which agreed to pay a $16.5 settlement to affected patients though it did not admit to charges that it participated in the alleged scheme.

Healthcare organizations can protect themselves from multimillion dollar settlements by paying attention to red flags and putting procedures in place to monitor procedures and claims. Working with a healthcare lawyer knowledgeable about insurance fraud can help clarify any confusion or uncertainty you may have about relevant regulations.

To prevent false claims and unnecessary procedures, your organization can implement internal control procedures such as these:

• Randomly select and review medical charts of patients who undergo tests and other procedures to confirm that the tests met the medical necessity guidelines for reimbursement.
• Set up notification alerts for doctors with a pattern of billing for services and care with no supporting documentation.
• Conduct regular audits to see how patient records and claims line up with patient questionnaires. A record that significantly contradicts a patient’s answers about symptoms or medical history may have been falsified to support billing for tests and procedures.

In addition to proactive measures to monitor for fraudulent practices, you should pay attention to internal and external complaints about providers. Conversely, a pattern of ignoring them might later be used against your company or practice as evidence of negligence.

If you have concerns about whether you are following regulations that pertain to Medicare and Medicaid billing, call a knowledgeable healthcare attorney at Hemmer DeFrank Wessels, PLLC or contact us online.