The Palm Beach Post reported on a Medicare fraud case that resulted in Dr. Isaac Thompson being sentenced to 4 years in federal prison. This sentence was imposed by the court even though the doctor apparently had many patients who thought very highly of him.
This is just one more example of the vigorous effort by the United States Department of Justice to investigate and prosecute healthcare fraud cases in Florida. According to the Palm Beach Post article the doctor submitted claims for treating 387 patients for a rare chronic spine disease when they did not suffer from the ailment. Each of the patients was a member of the Humana Medicare Advantage program under which a flat fee was paid for services. Medicare, however, allowed additional fees when treating this rare disease.
The 4 year sentence, while harsh, could have been worse. The time that the doctor will spend in prison is not the only consequence of this case. The doctor will, in all probability, lose his license to practice medicine and was ordered by the court to pay in excess of $2 million to the clerk of the Court for use as possible restitution.
An interesting aspect of this case is that Humana has been sued under the Federal whistleblower statute for its involvement in submitting false billing. The existence of this civil case will subject Humana to further investigation by the Department of Justice and may result in significant financial penalties if the government seeks to pursue an action for false claims.
Because of the perceived healthcare fraud problems in Florida, Medicare routinely monitors billing by doctors, hospitals and other healthcare providers. It is not surprising that a criminal prosecution resulted when one doctor submitted billing for 387 patients for treatment of a rare chronic health condition. At a minimum, any doctor or healthcare provider should expect an audit by Medicare, Medicaid or insurance companies to confirm that bills are legitimate and that services were actually provided.
While billing for a procedure may involve an error in coding, that is a far cry from billing for a treatment of a specific medical condition that the patient does not have. Errors in coding are not necessarily criminal but billing for services not provided is much harder to justify and defend.