Doctors Going to Jail: Criminal Prosecutions for Quality of Care and Fraud
When I was growing up (and probably for generations), every proud parent wanted their son or daughter to go to medical school. With the increasing role of government in healthcare and the changing economics, the profession has lost a bit of its luster.
Federal prosecutors are creative when it comes to developing new criminal enforcement initiatives. Over the years, federal prosecutors have taken civil laws and regulations and launched, new aggressive criminal enforcement programs.
A good example of such an initiative is the off-label marketing enforcement program. In the 1990s, off-label marketing was considered a civil or regulatory matter handled by the FDA. Now, it has become a criminal enforcement priority and has led to a number of large, high-profile settlements.
As part of the aggressive enforcement of healthcare fraud, prosecutors have started to focus on doctors for over-utilization of services, meaning doctors who seek federal reimbursement for services which are not justified under government standards of care. In its vigilance to root out all possible fraud in the healthcare system, prosecutors have turned their attention to charge physicians with criminal offenses when they improperly prescribe medical services.
Three cardiologists have now been prosecuted for over-utilization of heart stents. (Stents are metal tubes surgically inserted into a patient’s arteries in order to improve blood flow).
Most recently, a London, Kentucky cardiologist pleaded guilty to charges that he made false entries into health records in order to receive payment for numerous heart procedures. The physician will serve a prison term of between 30 and 37 months. St. Joseph’s Hospital in London, Kentucky, has repaid the government $256,800 for cardiac stent procedures that the physician falsely submitted for reimbursement.
Under Medicare regulations, heart stents are “medically necessary” only in cases in which a patient is suffering at least 70 percent blockage of an artery and related symptoms of blockage. In this case, the cardiologist prescribed heart stents in patients with less than 70 percent blockage, and then misrepresented the blockage percentage in the medical records to obtain Medicare reimbursement. In other words, the cardiologist over-prescribed the heart stent medical procedure.
The London, Kentucky cardiologist joins two other cardiologists in prison for the same offense – one in Louisiana was sentenced to ten years in prison for implanting stents and defrauding Medicare; and another in Maryland was sentenced to eight years in prison.
During the past five years, several studies have established that stents are not always necessary and, in fact, that the risks of stents may outweigh the benefits. Many cardiologists who previously recommended stents for their patients are recommending a drug regimen and lifestyle changes.
Cardiologists who recommend heart stents need to make sure they follow the specific requirements under the Medicare program and document carefully their actions to ensure that the procedure is medically necessary.
The federal government has focused on heart stents because of the clear standards governing their use and the high-cost of the procedure. As the purse strings tighten around Medicare, doctors can expect prosecutors to focus on other medical procedures and services where the risk of fraud is high.