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Healthcare fraud: St. Louis case yields one-year sentence

Medical billing is complex, often convoluted endeavor for all concerned. The Affordable Care Act, the formal name for the health insurance overhaul known as Obamacare, hasn't really changed that fundamental reality.

It should also be noted, however, that only a very small number of doctors participate in questionable billings. And even when there are questions, that does not necessarily mean charges of healthcare fraud are properly in order.

In a recent St. Louis area case, however, a doctor from University City pleaded guilty to Medicare and Medicaid fraud. He was sentenced last week to prison term of one year and one day.

The 62-year-old doctor must also pay restitution in the case.

Prosecutors contended that the doctor made a total of 276 false claims to Medicare and Medicare for services that weren't actually provided. Indeed, the doctor was apparently out of the country when these services were supposedly provided.

The amount in question on those claims was more than $26,000. According to prosecutors, the doctor also sought reimbursement from the federal government for nearly $93,000 in services for patient visits that were of shorter duration than the doctor claimed. 

The broader question, as we discussed in our February 25 post, is how the interaction of the Affordable Care Act (ACA) and the federal False Claims Act (FCA) may affect the investigation of suspected healthcare fraud going forward. In particular, it is important to keep in mind the distinction between civil and criminal charges.

In other words, criminal charges for healthcare fraud are not necessarily the appropriate vehicle for resolving all concerns about lack of compliance with medical billing guidelines.

Source: KMOX, "University City Doctor Sentenced For Medicare, Medicaid Fraud," July 11, 2013

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