Posts Tagged fraud

Don’t Get Caught in a Copay Conundrum

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Don’t Get Caught in a Copay Conundrum

In the current environment of increasing patient deductibles and copays, the billing and collection of the patient portion of the services you provide is top of mind. In the Department of Health and Human Service’s report dated May 23, 2017, Alabama’s average monthly health insurance premium amounts increased 223 percent from 2013 to 2017, versus the national average increase of 105 percent. In real dollars, average monthly premiums jumped from $178 to $575.

With deductibles and copay amounts increasing as well, it’s becoming more difficult to collect the patient’s portion of the bill. As a provider, you are more than aware of these financial hardships your patients are facing, especially your sicker patients who absolutely need care. You might routinely waive the patient portion of your services because you sense a financial issue. Maybe you treat other physicians or colleagues and write off their portion of the bill as a professional courtesy. You might even provide care to your team of employees at a reduced rate as a perk of their job. But did you know all three of these scenarios can land you in hot water?

These practices, while intended to be a gesture of goodwill, professional courtesy, or “it’s just the way we’ve always done things,” could put you and your practice at risk of violating federal anti-kickback statutes and violating contracts with insurance carriers – not to mention impacting your practice’s financial bottom line.

According to the Office of Inspector General, the federal Anti-Kickback Statute (AKS) is “a criminal law that prohibits the knowing and willful payment of ‘remuneration’ to induce or reward patient referrals or the generation of business involving any item or service payable by the federal health care programs.” Violating the federal Anti-Kickback Statute can lead to criminal penalties and administrative sanctions. The penalties for physicians who pay or accept kickbacks can be up to $50,000 per kickback plus three times the amount of the remuneration in question as well as imprisonment and exclusion from future participation in federal health care programs. The HHS’s A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud & Abuse states the following:

“…Where the Medicare and Medicaid programs require patients to pay copays for services, you are generally required to collect that money from your patients. Routinely waiving these copays could implicate the AKS, and you may not advertise that you will forgive copayments.” In this case, the HHS would determine a practice is violating the AKS if their standard practice is to waive copays. Patients would become the referral source and would be receiving the benefit of a waived copay.

From a commercial insurance carrier’s point of view, if you routinely write off patient’s copays and deductibles, you are in essence decreasing the total charge for the service you are providing. A $100 visit with a $20 copay that is routinely waived has now become an $80 visit.

Commercial insurance carriers can view this as a breach of contract, and they have recently been cracking down on enforcement of collections. Commercial carriers can stipulate that copay portion is required to be paid in order to reimburse the practice its portion. If they find out you have been waiving the patient portion for services, they can come back and seek repayment of funds they’ve already paid for those patients.

Profit margins for services are getting smaller and smaller, and as a medical practice in today’s post-ACA world, your bottom line can’t afford the consistent waiver, or poor collection of these copays and deductibles.

To navigate this issue, we recommend you review/update or implement policies and procedures guided by these best practices:

  1. Immediately stop any current practices of routinely waiving or reducing copays and deductibles.
  2. Where financial need is an issue, develop a policy with outlined procedures to document a patient’s financial hardship. Having a patient merely sign a document stating they have a financial hardship is not enough to substantiate the patient’s inability to pay. Have a designated staff person/financial counselor document the patient’s financial need. You need to perform due diligence with the patient to prove they are unable to pay. The HHS’s Roadmap for New Physicians states, “… you are free to waive a copayment if you make an individual determination that the patient cannot afford to pay or if your reasonable collection efforts fail.” Train front desk and billing staff on these policies and procedures to ensure consistent enforcement.
  3. Bill copays and deductibles and make adequate attempts to collect from the patient. We recommend at least three statements and a phone call as a best practice. Document all communication and collection efforts in the patient’s file to provide an adequate audit trail, should you need such information in the case of an audit.
  4. If these three practices bear no fruit, you can write off the patient’s copay or deductible.

As you can see, justifiable circumstances of financial hardship or need are situations where you can discount or waive patient copays. Use these best practices to implement consistent and reasonable policies and procedures. Steer clear of routine waivers and discounts of copays, and you shouldn’t find yourself in a copay conundrum.

The Do’s and Don’ts of Deductibles and Copays

What you should do…

  • Always bill the full amount.
  • Make a reasonable effort to collect from the patient.
  • When a patient states an inability to pay, establish policies and procedures to determine financial need and keep adequate documentation.
  • Work out a payment plan with a patient, or agreement for paying a certain amount each visit.
  • Collect up front rather than later. Each statement sent costs you time and money.

What you should not do…

  • Routinely or systematically write off copays or deductibles.
  • Advertise that you will forgive copays.
  • Accept the “in-network” copays if you are an “out-of-network” provider.
  • Devalue your services by waiving or reducing the copay and deductibles due.

The information in this article is not intended as tax or legal advice. Please contact your lawyer or CPA for specific information regarding your individual situation.

Article contributed by Jenna Roton, CPA, with Jackson Thornton CPAs and Consultants, an official partner with the Medical Association.

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Phishing Schemes Can Paralyze Your Medical Practice

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Phishing Schemes Can Paralyze Your Medical Practice

“Phishing” occurs when emails are sent to individuals or entities in an attempt to fraudulently gain access to personal information or introduce malware into the computer system. These emails are often disguised to look familiar to the recipient. The perpetrator may disguise their communication to appear to be from a colleague, family member or friend. They may also attest to be from a reputable source, like your bank, PayPal or other legitimate websites. They request that you click on a link or open an attachment. Fraudulent links will generally request that you update your information by entering your username or password. Some may ask for other types of personal information like address, date of birth, social security number or credit card information. Fraudulent attachments may contain malware, the most common being ransomware, which has had a significant impact on the health care industry.

What Is “Spear Phishing”?

Spear phishing is a specific kind of phishing that customizes its attack to specific individuals. For instance, the perpetrator may study an individual’s social media profiles and send them an email that appears to be from a co-worker or organization that they belong to. Just as with normal phishing exercises, the goal is for the target individual to click on a fraudulent link or attachment that will either provide the perpetrator with personal information or provide an opportunity to introduce malware into their computer system.

How Are Phishing Schemes Impacting Health Care Entities?

The threat of phishing activities to health care entities has steadily increased. Perpetrators are learning that the types of identifying information that health care entities attain and maintain are the exact types of identifiers they need to participate in a wide range of fraudulent activity from filing false tax returns to credit card fraud. These identifiers include data that health care professionals work with daily, like date of birth, social security numbers and health plan information.

When health care professionals fall victim to these phishing schemes it can threaten their entire organization. With the widespread use of Electronic Medical Records (EMRs), compliance professionals are seeing ransomware attacks on the rise as entity administrators attempt to recover their vital data.

Reduce Your Risk

  • Ensure that your entity has a clear and documented policy which addresses how employees should handle email communications. Some entities forbid accessing personal emails on work equipment while others set specific parameters. Your entity should determine the process that works best for your workforce and enforce that policy.
  • Train your staff on how they can identify phishing schemes and educate them on the threat that these schemes pose to your organization.
  • Ask your Information Technology (IT) personnel to send phishing emails to employees to test the number of employees who fall for phishing schemes after training.
  • Consider purchasing cyber insurance to protect your entity in the event of an attack.

Identify Phishing Activity

  • Often these fraudulent emails will have email links that are misspelled. For example, instead of customerservice@regionsbank.com, it may have customerservic@reggionsbank.com.  Those variations are small and often overlooked.
  • Be careful about the information that you share on social media. Try not to post personal information like your address, phone number and birth date.
  • Be suspicious about sites that attempt to redirect you to other similar looking websites.
  • If you think an email looks suspicious, contact your supervisor or HIPAA Security Officer so that it can be investigated properly.

Report Phishing Attempts

If you believe that you or someone that you know may have been the victim of a phishing attempt, there are a number of authorities that receive these reports and act to minimize their impact.

  • You may file a report with the Federal Trade Commission (FTC). Reports can be sent electronically at FTC.gov/complaint.
  • Reports can be made to APWG at reportphishing@apwg.org. This is an anti-phishing workgroup that analyzes and fights cybercrimes.
  • Always notify your IT support staff or your HIPAA Security Officer when you believe that you have received a fraudulent email so that they can investigate the email and take action to minimize the threat.

If you have questions regarding phishing and malware, or if you believe that it is time to update your entity’s policies and procedures, please consult a health care compliance expert.

Article contributed by Samarria Dunson, J.D., CHC, CHPC, attorney/principal of Dunson Group, LLC, a health care compliance consulting and law firm in Montgomery, Alabama. Find more of Ms. Dunson’s contributions on her partnership page. 

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The New Department of Justice Initiative: Aggressively Investigating and Prosecuting Opioid-Related Cases

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The New Department of Justice Initiative: Aggressively Investigating and Prosecuting Opioid-Related Cases

Before joining Burr & Forman, LLP, I was a federal prosecutor for a little over a decade specializing in health care fraud and general white collar matters. In that role, I was the member of a prosecution team that secured guilty verdicts earlier this year against two pain management doctors in Mobile, Ala., following a protracted jury trial. The doctors were convicted of a litany of federal crimes arising from their operation of a pain management clinic, including, among others, violations of the Controlled Substances Act and the Anti-Kickback Statute. The doctors received substantial prison sentences of 20 and 21 years, respectively, and forfeited virtually all of their assets (including bank accounts, houses and cars) to the government.

The doctors in this case were convicted of running what the government calls a “pill mill,” a pain management clinic that allegedly prescribes narcotics for illegitimate purposes. Pain management professionals should be aware this is just one example of what will likely be an onslaught of “pill mill” and other opioid-related prosecutions by the Department of Justice (DOJ) during the current administration. In fact, just a few months after the convictions in the Mobile case, Attorney General Jeff Sessions announced a nationwide takedown of 120 doctors, pharmacists and nurses – dubbed “Operation Pilluted” – who were charged with various federal crimes related to their alleged “unlawful distribution of opioids and other prescription narcotics.” In announcing the takedown, Sessions noted the DOJ would continue to “aggressively pursue corrupt medical professionals,” and “the Department’s work is not finished. In fact, it is just beginning.”

On the heels of that announcement, in August of this year, Sessions heralded a new DOJ pilot program called the “Opioid Fraud and Abuse Detection Unit.” According to Sessions, the unit “will focus specifically on opioid-related health care fraud using data to identify and prosecute individuals that are contributing to the opioid epidemic.” Sessions warned, “If you are a doctor illegally prescribing opioids or a pharmacist letting these pills walk out the door and onto our streets based on prescriptions you know were obtained under false pretenses, we are coming after you.” Sessions explained the DOJ would be appointing a special federal prosecutor in 12 select districts across the country whose sole purpose will be to prosecute “pill mill” and other opioid-related cases.

One of the districts, which has received one of the special “pill mill” prosecutors, is the Northern District of Alabama, in Birmingham. The U.S. Attorney for that district, Jay Town, separately confirmed the new prosecutor will spend “100 percent of their time working these types of cases…What we’re going after is the medical providers who are operating outside the boundaries of the law and the medical practice.” Echoing the Attorney General’s statements, Town vowed, “We’re going to rid the Northern District of these pill mills.”

Note “pill mills” are not the only opioid-related cases on the DOJ’s radar. In fact, it is also concentrating on the “diversion” of opioids in hospital settings. Such “diversion” schemes include, for instance, the theft of opioids from a hospital “Pxyis” machine (a device hospitals utilize to regulate the dispensing of controlled substances) by nurses, or the forgery or fraudulent creation of opioid prescriptions by hospital personnel.

In sum, the DOJ has fired a warning shot that physicians, pharmacists and other medical professionals involved in the treatment of patients will be under intense scrutiny for the foreseeable future. This is especially true for physicians who operate pain management clinics. These doctors should, in general, prescribe opioids reasonably and carefully in the context of each patient’s presentation and thoroughly document their treatment.

To that end, doctors should, among other things: maintain a thorough intake procedure, which requires the patient to give a detailed medical history and provide previous diagnostic studies; have the patient sign, if applicable, an “opioid treatment agreement” requiring the patient to abide by certain opioid use guidelines; perform exhaustive physical examinations during the initial visit and at regular intervals during the patient’s treatment (which should be carefully documented); consider alternatives to opioid treatment, such as non-narcotics drugs, physical therapy and surgery (and, where applicable, carefully document why alternative treatments would be ineffective); prescribe the lowest dosage and quantity of opioids possible to treat the patient’s condition; closely monitor for signs of diversion and addiction by regularly ordering urine drug screens and reviewing the patient’s prescription drug monitoring data; and have regular independent audits conducted by a billing consultant or another pain management specialist to ensure compliance with all regulations and laws. Implementing these practices should help doctors avoid government scrutiny as part of the DOJ’s new initiative to crack down on alleged “pill mill” operations.

Adam Overstreet is counsel at Burr & Forman, LLP. Prior to joining Burr, Adam practiced with the U.S. Attorney’s office and gained extensive experience with health care fraud matters. Burr & Forman, LLP, is a partner with the Medical Association. Please read other articles from Burr & Forman, LLP, here.

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Physicians Maintain High Standards

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Physicians Maintain High Standards

By the time this article goes to print, a lot could change, so there’s no apparent use in guessing what will come of the next Repeal and Replace efforts or what’s happening at Main Justice. Nobody knows. The only certainties from Washington are that there will be change in the payment and insurance models, and that there will be more reports of arrests and prosecutions for alleged fraudulent schemes. Some practitioners express concern, but physician quality and innovation do not have to suffer because of these changes in law because physicians maintain high standards.

Neither Obamacare nor Ryancare nor Trumpcare nor the next iteration will actually change health care. Instead, they guide how health care services are paid. Payment certainly can influence quality, just as who pays for care can perhaps impact patient compliance. But quality care is neither guaranteed nor premised on any particular actual or proposed national structure. These laws do not provide anyone health care. You do, as physicians and nurses and hospitals. The Medical Association began with 30 physicians having a common goal of higher standards in an era with no insurance market at all, nor anesthesia like we know it today. It has always been appropriate for physician entrepreneurship to drive innovation and quality care with it, but there are limits.

The limits have always been there. Whether the changes of today will raise or lower the standard of care within any specialty, or chill entrepreneurship and innovation, is up to each provider. Understanding the legal bounds is often difficult for physicians, and sound legal advice is crucial to success because for every one announced prosecution or indictment there are untold stories of civil corporate misdeeds and aggressive strategies where specialized counsel could have maintained the high standard.

The Department of Justice under Attorney General Jeff Sessions announced in a July 13 news conference that 412 people were charged for participating in health care fraud amounting to more than $1.3 Billion. Pharmacists in Mississippi recently pleaded guilty to fraud charges, with one admitting” that he conspired with others to select compounded medication formulas based on profitability, rather than on effectiveness or patient need,” and that he dispensed medically unnecessary medications. The other pharmacist admitted to “soliciting physicians and other medical professionals to write prescriptions without seeing patients for medically unnecessary compounded medications dispensed by the pharmacy.”

In Virginia, “[a] medical doctor and entrepreneur was sentenced to [10 years] in prison . . . for defrauding his former company’s shareholders and for failing to account for and failing to pay employment taxes.” Ohio-based companies and their executives recently “agreed to pay approximately $19.5 million to resolve allegations pertaining to the submission of false claims for medically unnecessary rehabilitation therapy and hospice services to Medicare,” not that the therapy wasn’t performed or quality care – just that it was excessive and driven by profit over patients. Louisiana clinical psychologists were sentenced for a $25.2 million Medicare fraud scheme involving both unnecessary therapy and therapies never performed. A Florida physician pleaded guilty for his role in pain pill diversion and Medicare fraud scheme. An Alabama federal court enjoined a pharmacy from “distributing adulterated, misbranded and unapproved new drugs in violation of the federal Food, Drug, and Cosmetic Act.” A Tennessee physician settled false claims allegations of distributing and billing Medicare for drugs that had not been FDA-approved. This is all according to the Department of Justice in just the last month. Expect more, whether it’s from General Sessions or a successor.

These headlines should educate rather than frighten the physician entrepreneur with high standards. Each case can educate an intelligent professional that while billing guidelines and corporate laws may have positive or negative impacts on quality, usually indirectly, your standard of care owed to your patient and your business partners does not have to regress. These providers who fell into trouble with the Department of Justice may truly be outliers.

The Virginia “physician and entrepreneur” sentenced in July abused his investors’ trust, stole their money, and provided fraudulent financial statements. That’s an extreme case, perhaps, but consider the same case but where the physician and his investors lost trust in each other purely because of a lack of communication after a series of misunderstandings, and maybe some ego or fear. Perhaps the misunderstandings were fueled by further misunderstandings of medicine by the investors and misunderstandings of business by the physician. But I speculate on a hypothetical ripped from these DOJ headlines. Further, though, consider where the physician did not intend to steal anything but made blindly ignorant mistakes because he failed to ask for help or just maintained business as usual despite corporate changes. Consider the same story but where the financials were not intentionally fraudulent but in error or premised on aggressive billing practices, or an unwillingness to fully engage accountants for their services to pinch pennies. These seemingly more benign circumstances could be all too common, aggravated further by ego and competing visions or interests, and if unchecked and don’t make the DOJ alert then they could also lead to civil lawsuits.

A health care lawyer can answer questions and guide physicians to maintain high standards. The honest physician in need of compounded pharmaceuticals for patients could unwittingly become a co-conspirator like the Mississippi physician. The honest clinician is being driven to cut costs and increase revenue. The honest physician is brought into seemingly prudent arrangements that can turn sour. When a physician goes beyond medicine and into business, retaining legal counsel is critical to maintaining the same high business standards as physician strives for high standards in caring for patients. Specialists and trained sub-specialists are available.

Tom Wood is a partner in the Health Care Practice Group at Burr & Forman LLP and represents health care providers in regulatory and litigation matters. Buff & Forman LLP is a partner with the Medical Association.

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Four Types of Identity Fraud on the Upswing

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Four Types of Identity Fraud on the Upswing

If you thought that the promising (albeit modest) drop in the total dollars stolen by identity thieves in 2015 was a harbinger of things to come, think again.

According to the just released 2017 Identity Fraud Study from Javelin Research, the number of victims of this crime—in all its permutations—climbed to a record high of 15.4 million last year. And, despite the fact that the average amount per fraud went down, the total cost topped $16 billion, also an all-time high. What does that say about efforts to rein in identity thieves?

“We’ve gotten pretty good at closing the door once the horse has left the barn,” says Al Pascual, Javelin senior vice president and head of fraud and security. But we need work when it comes to “barring the door” to begin with.

The research, funded by LifeLock, also made clear that even if you don’t maintain a large online presence, taking steps to protect your identity is a smart move. Offline consumers are less likely to experience fraud, Pascual explains. But when it happens it’s worse, because it takes more time to detect. On the other hand, if you’re highly connected, your risk is much higher than average. But you’re also likely to detect—and shut down—attempts at fraud more quickly. How do you protect yourself? “If you’re not digitally inclined, sign-up for a credit protection service,” Pascual says. “If you are, don’t use the same passwords even across retailers.”

The study, now in its 14th consecutive year, highlights a number of specific places identity fraud and theft are on the rise or particularly troubling. Here’s a look at what they are and how to protect yourself:

Card Not Present Fraud

What you need to know: Incidences of this type of fraud, where a thief uses your card number without having the actual card, rose 40 percent last year. Pascual expects those gains to continue. “We’ve gone digital because it’s convenient,” he says. “So have criminals.”

How to guard against it: Take advantage if your credit card offers ways to obscure your payment details, advises Dr. Stephen Coggeshall, Chief Analytics and Science Officer of ID Analytics. Some credit card issuers and fraud protection services will send you alerts if a charge is made and your card is not present. Do that as well. And pay attention to your credit card statements, watching, in particular, for charges you don’t understand.

New Account Fraud

What you need to know: This form of fraud, where a thief steals enough of your identifying information to open an account in your name, is on the upswing. Incidents nearly doubled from 2014 to 2015, and this year showed “almost the same degree of growth,” Pascual said. Importantly, the new accounts being opened are not just at traditional lenders, but also at alternative ones, including payday lenders and peer-to-peer lenders. Those are tougher to track.

How to guard against it: Monitoring your credit, by either taking a very consistent look at your own reports or having a service do it for you, is the key here. One advantage of some services, notes Pascual, is that they look beyond the item on your credit reports to checking and savings accounts and alternative lenders. Also, it sounds run of the mill, but open every piece of mail you get from a financial institution—even those you don’t patronize. Often, you’ll receive notice when an account is opened in your name, giving you a chance to shut it down and alert the credit bureaus.

Account Takeover Fraud

What you need to know: This type of fraud is distinguished by the fact that a criminal is essentially trying to usurp control for a pre-existing account that you’ve set up. Signs that it might be happening include receiving change of password or change of address notices that aren’t prompted by your actions. “These cases result in the highest average loss amount, and sometimes a consumer can be stuck for more of the bill,” says Pascual, explaining that it can be difficult to prove that you didn’t take the actions involving your account, such as removing or spending funds.

How to guard against it: Don’t reuse passwords across sites—particularly across financial ones. Criminals will take the password list from one breach and try those passwords at every major bank across the country to see if they can be used. Tell your financial institutions you want multiple notifications—by both text and email—if actions are taken on your account. “The idea is to make it harder for communication to be severed between you and the institutions,” says Pascual. And if two-factor authentication is available for entry to any of your financial sites, use it.

Sophisticated Phishing

What you need to know: The phishers have gotten better at their game. “We’re used to seeing phishing with poor misspelling, bad grammar, and poor formatting,” says Coggeshall. Criminals have moved beyond that. Today, corporate emails are being spoofed and employees are being sent letters from the CEO or finance department that look legitimate. In some cases, hackers take the time to learn things about you specifically, then target you with a specially crafted phish.

How to guard against it: If someone contacts you that you’re not used to hearing from and asks for any sort of financial or identifying information, a bell should go off in your head. Don’t click on the email. Don’t give out information by phone or text. Instead, back away and—if you believe it might be real—initiate the communication yourself to figure out if the need is legitimate.

LifeLock is a partner with the Medical Association, and physician members receive discounted rates on LifeLock memberships.

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Fraud and Abuse Investigations Should Be Taken Very Seriously

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Fraud and Abuse Investigations Should Be Taken Very Seriously

Editor’s Note: Burr & Forman LLP is sharing this information as a partner with the Medical Association and would like physicians to understand that the federal government is being vigilant with all health care fraud and abuse investigations. If you have questions concerning the content of this article, please contact Jim Hoover of Burr & Forman LLP at (205) 458-5111 or jhoover@burr.com.

For the United States Government, fraud and abuse recovery has an excellent return for each investment dollar spent. According to the Health Care Fraud and Abuse Control (HCFAC) Program Report, released by the Department of Health and Human Services and the Department of Justice on Jan. 18, 2017, the federal government recovered more than $3.3 billion in fraudulent health care claims in Fiscal Year 2016. That means for the last three years for every dollar invested into the program it generated a $5 return.

Established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the HCFAC Program was designed to identify and prosecute health care fraud and abuse through the coordination of federal, state, and local law enforcement activities. Since its inception in 1997, the program has returned close to $31 billion to the Medicare Trust Funds.

According to the program report, during FY 2016 the Federal Government won or negotiated over $2.5 billion in health care fraud judgments and settlements. Of the $3.3 billion, the Medicare Trust Funds received transfers of approximately $1.7 billion, and $235.2 million in Federal Medicaid money was similarly transferred to the Medicaid program. Over $17.9 billion has been returned by the program to the Medicare Trust Funds for years 2009 through 2016 alone.

Other notable results of the program include, the disclosure that for FY 2016 alone, the DOJ opened 975 new criminal health care fraud investigations that led Federal prosecutors to file criminal charges in 480 cases involving 802 defendants. A total of 658 defendants were convicted of health care fraud-related crimes during the year. On the civil front, in FY 2016 the DOJ opened 930 new civil health care fraud investigations and had 1,422 civil health care fraud matters pending at the end of the fiscal year.

HHS’ Office of Inspector General (HHS-OIG) investigations conducted in 2016 resulted in 765 criminal actions against individuals or entities that allegedly engaged in crimes related to Medicare and Medicaid. There were 690 civil actions, which include false claims and unjust-enrichment lawsuits, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosures. HHS-OIG also excluded 3,635 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs. Among these exclusions, some were based on criminal convictions for crimes related to Medicare and Medicaid (1,362) or to other health care programs (262), for patient abuse or neglect (299), or as a result of licensure revocations (1,448).

There were multiple highlighted cases involving physicians. In April 2016, a doctor in Maryland specializing in interventional pain management was sentenced to nine years and three months in prison, followed by three years of supervised release for one count of health care fraud, two counts of making a false statement related to a health care program, one count of obstruction of justice, four counts of wire fraud, and one count of aggravated identity theft. The convictions were based on allegations the doctor submitted claims for nerve block injections when in fact the doctor did not own nor use imaging guidance which was necessary to administer nerve block injections. The doctor also falsely documented patient files to indicate that imaging guidance was used. Finally, when Medicare contractors visited the pain clinic and inquired about the imaging guidance machine, the doctor created a false lease document reflecting the fact that he had leased the machine.

In April 2016, a licensed physician pleaded guilty to health care fraud, admitting that he submitted false claims to Medicare for purported visits with Medicare beneficiaries, including on dates when he was out of the country, for beneficiaries who were deceased on the dates he purportedly treated them, and for services totaling more than 24 hours in one day. He agreed that he submitted approximately $2.4 million in fraudulent claims to Medicare for which he was paid approximately $1.2 million.

In July 2016, following a three-week trial in the Eastern District of New York, a physician was convicted of one count of health care fraud, three counts of making false statements in connection with health care matters, and two counts of money laundering. The evidence at trial showed the defendant, a general surgeon, billed the Medicare program for thousands of wound-debridement and incision-and-drainage surgical procedures that he did not in fact perform. The defendant billed Medicare over $7 million and was paid over $3 million in reimbursement by Medicare.

It is a safe bet to assume based on the above returns government investigations and qui tam/false claims lawsuits are here to stay no matter who is President. To read more about the 2016 results and upcoming initiatives, the program reports are located on the HHS-OIG website .

Jim Hoover is a member of Burr & Forman LLP’s Health Care Industry Group and represents health care providers in healthcare regulatory and litigation matters.

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Alabama Power Warns of Power Scam

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Alabama Power Warns of Power Scam

*Editor’s note: After being contacted by several physicians, we contacted Alabama Power for additional information concerning the resurgence of an old scam.

The Medical Association is joining Alabama Power to warn customers about a new wave of an old scam.

In this instance, scammers call from toll-free numbers claiming that the customer’s account is past due and the customer’s service will be discontinued if the customer does not make a payment.

The number features a recording claiming to be Alabama Power; however it is not. Alabama Power does not conduct business in this manner.

If receiving a call, do not rely on caller ID, as thieves alter the number on those devices to appear local, or even display “Alabama Power” or “Customer Service.”

Customers who receive suspicious calls are encouraged to hang up, and report it to law enforcement. The next call should be to your utility company’s billing department to confirm your account status and alert them of the scam.

Over the past few years, scammers targeting both residential and commercial customers have become more sophisticated in their tactics, including:

  • Calling from a local number posing as an Alabama Power technician threatening to disconnect service if a payment was not made immediately with a “money pack” or prepaid card – an untraceable disposable debit card. The scammers ask customers to buy a prepaid card from a local retailer (such as Walmart, CVS or Walgreens).
  • Using a number with “Alabama Power” appearing on the caller ID asking for immediate payment by money pack or prepaid card. The customer is then directed to call a different number with an answering machine that says “This is Alabama Power” and leave the prepaid card information.
  • Going to customers’ homes impersonating Alabama Power employees offering to reduce energy bills by conducting an energy audit. The fake employee offers to immediately credit the account by accepting a cash payment on the spot.
  • Targeting customers in chat rooms posing as employees of companies or organizations that help pay bills for disadvantaged families.
  • Going door to door and posing as clergy telling customers they are assisting people with paying their energy bills and asking for a prepaid card.

Most scams seem obvious after the fact, but scammers are smart and know they do not need to make sense; they just need to scare the intended victim. Their goal is to make the victims believe they are in trouble and that the scammers are the only ones who can help. This type of emotional manipulation is easy when it comes to a vital service such as electricity that customers depend on.

“If someone calls and says your electricity is being turned off unless you make an immediate payment, we urge customers to hang up and call their local authorities,” said Security Manager Scott Stover. “These are crimes that should be reported to law enforcement.”

Stover said after notifying local authorities, a customer’s next call should be to the Alabama Power customer service line to confirm their account status and alert the company of the scam.

“Due to the variety of scams, it is important our customers know the ways in which we conduct business so they can spot a scam and report it to authorities and to us,” Bellamy said.

How to protect yourself

Alabama Power customers should remember:

  • Alabama Power employees will never come to your door and demand an immediate payment.
  • No employee will ever call and ask you for bank information or a credit card number.
  • Any Alabama Power employee who comes to your door for any reason will have company identification that he or she will gladly show. If you have any questions about whether the person works for Alabama Power, call 1-888-430-5787 and do not let the person inside your home until you receive proper verification.
  • Scammers sometimes claim they represent a public agency or government office offering grants that can pay your Alabama Power or other utility bill. Never provide anyone making this claim your credit card information, your Alabama Power Company bill information or account number, or any personal banking information. If someone makes this claim, call Alabama Power or your local police department to report it.

If you ever have any question about the status of your Alabama Power account, do not hesitate to call the company. You can reach Alabama Power Customer Service day or night, seven days a week, at 1-888-430-5787.

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