Kusserow’s Corner: Recent Enforcement Actions Against Physicians

A lot of enforcement actions against institutional providers and managed care organizations gain wide press, but actions taken against physicians appear to be less-often noted. In fact, many are prosecuted, not only at the federal level but by state authorities as well. The following illustrate this by highlighting some recent cases involving individual physicians found to being engaged in wrongful activities.

Physicians Mansour Sanjar and Cyrus Sajadi, owners of Spectrum, were convicted of conspiracy to commit health care fraud and conspiracy to pay kickbacks as well as related counts of health care fraud and paying illegal kickbacks for approximately $97 million. They signed admission documents and progress notes certifying that patients qualified for partial hospitalization program (PHP) services, when in fact, the patients did not qualify for or it, as well as billing Medicare for those services when the beneficiaries were actually watching movies, coloring and playing games–activities. Patient recruiters received kickbacks for referrals and in some cases, the patients received a portion of those kickbacks.

Dr. Yash Khanna in Livingston, N.J., pleaded guilty to receiving over $10,000 worth of illegal cash kickbacks in exchange for referring patients to a diagnostic testing center and faces up to five years of imprisonment per anti-kickback charge. Khanna also admitted to not filing tax returns for three years. This was the 15th doctor to be convicted in connection with the fraud investigation.

Jose Mercado-Francis, a former Detroit-area physician, pleaded guilty for his role in an $11.5 million health care fraud scheme. He held himself out as a licensed physician and purported to provide physician home services to Medicare beneficiaries, when actually his medical license had been revoked. He operated out of a medical practice owned by a co-conspirator. He prepared medical documentation and signed them as if they had provided services to Medicare beneficiaries, when, in fact, they had not. The scheme involved than $11.5 million for the cost of physician home services.

Dr. Chang Ho Lee, Palisades Park, N.J., pleaded guilty to health care fraud and agreed to forfeit more than $3.4 million in fraud proceeds. He and two others recruited patients by offering free lunches and recreational classes and provided them with spa services, such as massages and facials, then falsely billed Medicare for more than $13 million using those patients’ Medicare numbers. They then billed Medicare for physical therapy, lesion removals and other services that were neither medically necessary nor provided.

Dr. Eguert Nagaj and chiropractor Igor Sher were indicted on 16 counts each of mail fraud in connection with a decade long health care fraud of nearly $3 million. They were in charge of three medical practices in Buffalo Grove, Ill., where they allegedly were involved in a scheme to fraudulently bill insurers for health care services that were not provided.

Dr. Mikhail L. Presman, a Brooklyn, N.Y. psychiatrist, was sentenced to three years of supervised release following his prison term and ordered to forfeit $1.2 million and pay restitution for falsely claiming to provide at-home services to Medicare beneficiaries in the amount of $4 million in Medicare claims for home treatment of Medicare beneficiaries notwithstanding his full-time salaried position as a psychiatrist at the VA hospital in Brooklyn. He did not provide any treatment to a substantial number of the beneficiaries he claimed to have treated and submitted claims to Medicare for 55 home medical visits to beneficiaries who were hospitalized on the date of the purported visits.

Dr. Lafayette Twyner, who practiced in Newton, pleaded guilty to health care fraud for billing private insurers for unnecessary prescriptions and medical services and for illegally prescribing drugs, which resulted in one death. He will serve five years in prison and three years in home confinement or in community corrections.

Dr. Roque Joel Ramirez, of Corpus Christi, Texas, pleaded guilty to mail fraud related to a $1.4 million health care fraud case. He owned Health Resolutions that submitted almost 5,000 false claims, including treatment claims for deceased patients.

Dr. Viwathna Bhuthimethee, in Alton, Ill., pleaded guilty to health care fraud and 14 counts of illegal distribution of controlled substances and improperly prescribing 1,585 pain pills with hydrocodone and 562 Xanax pills.

Christopher Gregory Wayne, dubbed the “Rock Doc” of Miami Beach, Fla., pleaded guilty to defrauding the Medicare program and illegally prescribing painkillers and fraudulently billing for more than $5 million worth of un-provided or unnecessary physical therapy services. He is required to pay more than $2 million and surrender his home and car to the government and, in exchange, 14 previous health care fraud charges will be dismissed

Dr. Spyros Panos, an orthopedic surgeon, of Dutchess County, N.Y., pleaded guilty to defrauding private health insurers, and was sentenced to four and a half years in prison and two years of post-release supervision. Panos’ plea agreement also requires him to pay restitution of as much as $5 million to the insurers and pay $5 million to the government

Dr. Donald Prohovich, a dentist practicing in Easton, Mass., and a dental provider for MassHealth, the state’s Medicaid program, settled allegations of fraudulent billings for $400,000 for house calls made to beneficiaries residing in nursing homes.

Dr. David Lewis, a dentist in Sacramento was charged with health care fraud in an alleged $1 million fraud case by targeting insurance beneficiaries, fraudulently billing the company for un-provided and medically unnecessary dental services, and offering cash incentives in exchange for treatment at his clinic and recruiting other patients.

Dr. Spencer Wilking, former medical director for MJG Management Company in Waltham, Mass., pleaded guilty to participating in a health care fraud scheme where he authorized hundreds of ineligible Medicare beneficiaries to receive home health services, costing Medicare more than $27 million.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.