Radiology is under the spotlight for fraud-related activities again, highlighting the harsh consequences of compliance failures and fraud. National Interventional Radiology Partners PLLC (NIRP), its founder, and its CEO were prosecuted under the False Claims Act (FCA) and Anti-Kickback Statute violation allegations. However, the defendants reached a settlement with the United States, agreeing to pay the sum of $8,884,091. In related news, the Department of Justice (DOJ) released its annual report on healthcare fraud, showing the staggering extent of its impact on the healthcare system. Both cases serve as reminders and a warning that the government, with its many judicial arms, will prosecute criminal actors, whether the fraud is intentional or accidental.
Dr. Andrew Gomes, 48, reached a settlement for illegal activities performed under NIRP. The settlement outlines that he created a scheme to illegally pay physicians for referrals to clinics that provided surgical treatment for patients experiencing peripheral arterial disease (PAD). PAD is a circulatory disease that results in plaque build-up in arteries and usually affects elderly individuals. Both the investigation and resolution of the allegations were the outcomes of joint work between the U.S. Attorney’s Office for the Southern District of Texas, DHHS-OIG, and the FBI.
The settlement states: “Beginning in 2015, Gomes established a number of clinics throughout Texas under the NIRP umbrella to surgically treat PAD. Gomes raised capital for these clinics from physicians who had medical practices that would provide a strong patient base for Medicare referrals, including primary care physicians, doctors of podiatric medicine, and family practitioners. Gomes’ pitch to the investor physicians was that they could ensure high returns on the investment in each surgical center from referring significant numbers of patients for treatment. Gomes told the investing physicians that more patient referrals would lead to more revascularization surgeries and higher profits – which funnels back to the investing physicians as monthly dividends.”
Gomes claimed to physicians that once operational and making a profit, these surgical centers could be sold, resulting in increased value for investors. Surgeries such as arteriograms, angiograms, angioplasties, and atherectomies help revascularize the lower limbs of patients with PAD; they are considered high-value, high-reimbursement procedures.
“Dr. Gomes and NIRP clearly prioritized greed above the health and well-being of their elderly patients,” said FBI Houston Special Agent in Charge Douglas Williams in a DOJ press release. “We applaud the qui tam whistleblower who exposed this scheme and encourage others to report illegal medical practices. FBI Houston will continue to identify and investigate those who would undermine the integrity of our healthcare system for their own financial gain.”
The civil settlement brings resolution to the claims filed under the FCA. It is important to note that under the FCA, private parties may file an action on behalf of the United States while being eligible to receive a portion of the recovery. The investigation was initiated by a complaint filed at the end of 2018. In this case, the whistleblower is entitled to 19% of the total recovery of $1,687,977.
This year, the DOJ announced results from its 2024 National Health Care Fraud Enforcement Action. The department’s press release revealed that just 193 defendants are responsible for $2.75 billion in intended losses and $1.6 billion in actual losses. These defendants comprise a variety of healthcare professionals, “including 76 doctors, nurse practitioners, and other licensed medical professionals in 32 federal districts across the United States,” the DOJ stated.
Through the efforts of multiple agencies, the government seized more than $231 million in illicitly purchased luxury vehicles, gold, cash, and other assets. The schemes include everything from laboratory testing to telehealth fraud, opioid schemes, HIV medication scams, and general healthcare fraud.
In the press release, U.S. Attorney General Merrick B. Garland, stated: “It does not matter if you are a trafficker in a drug cartel or a corporate executive or medical professional employed by a health care company, if you profit from the unlawful distribution of controlled substances, you will be held accountable. The Justice Department will bring to justice criminals who defraud Americans, steal from taxpayer-funded programs, and put people in danger for the sake of profits.”
Principal Deputy Assistant Attorney General Nicole M. Argentieri, head of the DOJ’s Criminal Division, stressed the systemic impacts of healthcare fraud on the system and everyday Americans stating: “Healthcare fraud affects every American. It siphons off hard-earned tax dollars meant to provide care for the vulnerable and disabled. In doing so, it also raises the cost of care for all patients. Even worse, as the prosecutions we announce today underscore, healthcare fraud can harm patients and fuel addiction. The Criminal Division is committed to rooting out healthcare fraud, wherever it may be found, no matter who commits it. And we are using more tools than ever before to uncover misconduct and hold wrongdoers to account, whether they are executives in corner offices or doctors who violate their oaths.”
Both the individual radiology case and the DOJ’s report serve as a clear warning about the impacts of healthcare fraud and the government’s willingness to use every resource at its disposal to prosecute criminal actors.
Information Sources:
Election Day has finally arrived – however, some physicians may not be celebrating the new 2025 Medicare Physician Fee Schedule (PFS) Final Rule that also
As the November elections neared, you might have expected Washington to slow to a crawl amidst campaigning and uncertainty about the future. However, the show
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
