Fraud, Waste and Abuse Monthly Round Up April 2025

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

PSR Case Reports January and February 2025

In the months of January and February 10 section 92 agreements came into effect. Seven of the agreements were made with GPs, one with a radiation oncologist, one with a psychiatrist and one with an anaesthetist. Four GPs and the psychiatrist were disqualified from billing certain items for a period. The maximum repayment across all practitioners for December was $595,000, which was enforced against a GP who rendered and prescribed MBS item 732 (review of a GPMP) and PBS item 3162K (diazepam 5mg) in excess of 99% of their peers. It is worth mentioning that the PSR is not restricted to investigating only certain MBS or PBS items. Once you are under review, the PSR can review every item you bill across your universe of claims. This GP was reviewed for numerous MBS and PBS items and was found to have breached the 80/20 rule, not met time requirements, not met item description requirements, and some services were not clinically relevant. Some patients were not eligible for the services provided and record keeping was inadequate. There was insufficient individualisation where templates had been used. This provides another reminder about templates. Copying and pasting without sufficient individualisation is regularly reported by the PSR, causing providers to fall foul of legal requirements. The radiation oncologist was not disqualified and was required to repay $300,000. This practitioner was found to have not met complexity requirements for some items and had serially upcoded others. We expect the reason there was no disqualification was that a third-party company was doing the billing without the knowledge of the practitioner. This is speculation of course, but we hear about it often. It is a reminder that you are responsible for your billing no matter who administers it for you. The psychiatrist was ranked in excess of 99% of their peers across a wide range of time-based items, both face-to-face, telehealth, management plans and third-party interviews. There were some very serious findings resulting in disqualification and a repayment of $500,000. Findings against this practitioner included not meeting time requirements and/or item descriptors, inadequate record keeping (sometimes illegible sometimes non- existent), services were not always clinically relevant and clinical management was inadequate for some patients. Seeing an anaesthetist on the report was a first (well a second but this is still very rare). There is only one other anaesthetist who has ever been reported since reports were made public as far as we are aware, and his case is quite different to this one. This anaesthetist was required to repay $200,000. The practitioner was ranked first compared with all active anaesthetists across a range of items, including the long pre-anaesthetic consultation item 17625. The practitioner was also ranked second for another long pre-anaesthetic consultation item 17615. There was also a range of typical add-ons and modifiers for anaesthetic billing including blood transfusions (ranked first for this item), restoration of cardiac rhythm, emergency after-hours anaesthesia and more. Findings against this practitioner were that item descriptor requirements were not met including minimum time requirements and record keeping was inadequate. This is a cautionary tale for all anaesthetists. The PSR clearly has this specialty on its radar and billing high volumes of long pre-anaesthetic consultations (17615-17625) is likely to bring you to their attention. Once you are under investigation every item you bill will be investigated. You can access the January and February PSR case reports here.

FWA around the world

United Healthcare reportedly being investigated for its Medicare billing practices According to a report in the Wall Street Journal, subsequently reported in other news outlets, the US department of justice is conducting a civil fraud investigation in relation to United’s Medicare billing practices. This comes on the back of the recent killing of United’s CEO. In addition to its health insurance operations, United has other business lines that involve physician practices. It is alleged that United is using patient’s diagnoses to illegally increase the amounts it receives from the US Medicare Advantage program. There are some interesting articles about this at these links: https://www.wsj.com/health/healthcare/unitedhealth-medicare-doj-diagnosis-investigation-66b9f1db https://www.theguardian.com/us-news/2025/feb/21/united-healthcare-justice-department-investigation https://www.cnbc.com/2025/02/21/unitedhealth-faces-doj-investigation-buyouts-stock-price-drop.html Doctor and two associates convicted of over $8 million in Medicare and Medicaid fraud Dr José Alzadon, aged 61, Michael Bregenzer, aged 52, and Barbie Vanhoose, aged 62, were convicted by a jury for their health care fraud scheme operated through drug addiction clinics. The fraud playbook in this case was unfortunately a common one involving billing for services not provided, billing for more complex services than those provided and billing in the name of a family member to bypass insurance authenticity checkpoints. The family member was the father of the doctor who had prescribing rights, but he had never seen many of the patients for whom he supposedly issued prescriptions. Significant jail terms are likely, and sentencing will be decided in June 2025. You can read the Department of Justice report here. Chiropractor convicted of fraud  Chiropractor, Dr Benjamin Tekippe, aged 40, actively solicited insured patients and advertised his service as “free”. He then routinely billed the insurer for services he didn’t provide. He submitted over $2.3 million in fake claims and was reimbursed approximately $740,000. The jury found him guilty after hearing evidence that thousands of the fake claims were allegedly provided on dates when he was out of the office, travelling, or in jail. There was also evidence of fabricating patient records and spending proceeds on luxury goods and gambling. He was also found guilty of unemployment insurance fraud. Tekippe will be sentenced in July and is looking at a maximum penalty of 20 years jail for the unemployment fraud and 10 years jail for each of the 6 health care fraud counts he was convicted of. You can read the Department of Justice report here.