Healthcare Fraud Remains Rampant in 2024, DOJ Reveals

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.

Houston Radiologist Under Fire

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.

2024 National Healthcare Fraud Enforcement Consequences

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:

https://www.justice.gov/usao-sdtx/pr/nirp-and-founder-pay-nearly-9m-resolve-alleged-kickback-referral-violations

https://www.justice.gov/opa/pr/national-health-care-fraud-enforcement-action-results-193-defendants-charged-and-over-275-0