Last year, a sober home director pleaded guilty to stealing over $30 million from Medicaid. The scheme essentially mined substance abuse patients for capital. The sober home would submit false claims for urine tests to providers who would then bill Medicaid for the tests. Authorities say that the tests were either unnecessary, were not billed properly, or didn’t actually exist.
Now, a respected psychiatrist has been pulled into the scheme and is facing charges related to health care fraud. However, his attorneys say that he is just another victim of the notorious conman who used those in recovery as a cash cow. The U.S. attorney who is prosecuting the doctor scoffed at his defense and believes that he knew that the company was charging for unnecessary medical tests.
The operation ran for four years before it was shut down by the FBI. Now, the ringleader is going to prison and a psychiatrist is facing 20 years behind bars. These schemes generally are uncovered when one sober home or health care facility charges much more than other similarly situated facilities. When prorated across the cost of an individual patient, the records show that each patient costs much more to treat than other similar facilities. The government then asks, “Why are we paying more to this sober home than to other sober homes”. At this point, they launch an investigation. While the scheme managed to net $30 million, the proceeds will be liquidated to repay the costs associated with the fake urine tests. Plus, the sober home operator will spend a significant amount of time in federal prison.
Is the doctor responsible?
Both parties have been charged with conspiracy to commit health care fraud and then individual counts of filing false claims. In order to prove this, the government must establish that the doctor knowingly submitted claims that he had good reason to believe were false. In this case, the doctor was helping the sober home operator order three urine tests a week. In addition, these were the most expensive urine tests that you could purchase. They look for drugs that aren’t even addictive. In other words, these overly-expensive and precise tests were extreme overkill, and to order them three times a week was even more so. In some cases, the doctor would order new tests even before he’d received the results of old tests. The number of orders overwhelmed the laboratory processing the requests. In other words, no reasonable doctor would order those particular expensive tests at that rate, according to the federal government. Of course, the doctor will say he was just being diligent.
Now, the prosecution will then counter that if it was diligence that spurred the doctor to order a massive quantity or expensive tests, then why weren’t the results of those tests being reviewed prior to ordering new tests? In other words, the doctor’s defense is in a bit of trouble. The doctor maintains that the type of testing he ordered was appropriate to the task and a matter of personal policy and belief in routine testing for the treatment of addiction.
Lastly, the government must show that the doctor benefited from the fraud. This could be the reason why the defendant wins. The defendant did not receive direct proceeds from the fraud but instead worked on a contract. If there is no financial benefit to the doctor, then there is no fraud. The sober home owner simply capitalized on a doctor who really believed in testing to treat substance abuse.
Talk to a West Palm Beach Criminal Defense Attorney
If your employer made millions pocketing insurance money and you never saw a dime of that money, you are not guilty of fraud since the government must establish that you financially benefited from the deception. No benefit, no fraud. Call the West Palm Beach criminal lawyers at The Skier Law Firm, P.A. today.