Fraud, Waste and Abuse Monthly Round Up August 2025

Monthly round up Here’s a summary of PSR cases and other FWA activity

PSR Case Reports June 2025

In the month of June 8 section 92 agreements and 3 final determinations came into effect. Four of the agreements were made with General Practitioners, and one each with a Nurse practitioner, Dermatologist, Nephrologist and a General Physician/Geriatrician. Four practitioners were disqualified. The decision not to disqualify the other four was surprising in our opinion, especially the dermatologist who exploited the Extended Medicare Safety Net (EMSN) by charging egregious fees to the patient that led to significant cost to the Commonwealth. That’s the first time we have seen EMSN abuse reported. The item number was – 45506: SCAR, of face or neck, not more than 3 cm in length, revision of, where undertaken in the operating theatre of a hospital, or where performed by a specialist in the practice of his or her specialty – was uncapped so ripe for abuse. It has since been removed from the MBS. Only two of the three final determinations have been published. The third will be published “at a later date.” One of the two published related to a General Practitioner, and the second was a Cardiologist. Both were disqualified – the Cardiologist for a full 12 months from all MBS items. The Cardiologist was ordered to repay the highest amount this month - $1,900,000! We cannot stress enough the importance of meeting all requirements of every item you bill every time you bill it – no exceptions AND the threshold decision even before item selection – the service must be clinically relevant. The Cardiologist was found to have been providing exercise ECGs and stress echocardiograms (there must have been a lot given the repayment order) that were not clinically relevant, and item 132 reared its ugly head repeatedly across these cases. If you don’t spend 45 minutes with the patients AND create a complex management plan on a patient with at least 2 morbidities – you must not bill this item. You can access the June PSR case reports here.

FWA around the world

Nurse Practitioner convicted of $12M Medicare Fraud. On 24 July 2025, Scharmaine Lawson Baker, 58, was convicted for over $12.1 million in Medicare fraud by ordering cancer genetic tests that were not “medically necessary” (that’s the US equivalent of our “clinically relevant” standard). One of the most alarming aspects of this case was that Ms Baker had held herself out as an expert in Medicare regulations and had authored numerous publications on relevant standards and patient-provider relationships. She then breached the very same standards. Ms Baker worked as an independent contractor for a telehealth company signing hundreds of orders for the tests after phone calls that typically lasted less than 60 seconds. She did not examine the patients and falsely diagnosed some to justify the tests – including diagnosing male patients with cervical cancer. Ms Baker did not review test results even when the results showed a predisposition for cancer. Ms Baker will be sentenced on 19 November 2025 and faces up to 10 years in prison on each count. You can read it here. $16M Medicare Hospice Fraud and Money Laundering Scheme Juan Carlos Esparza, 33, has entered a guilty plea for defrauding Medicare of $16 million and laundering the proceeds. Esparza and his co-defendants operated four sham hospices and billed Medicare for hospice services that were not medically necessary and never provided. He will be sentenced on 6 October 2025 and faces up to 10 years in jail for healthcare fraud and another 10 for money laundering. You can read it here.