Fraud, Waste and Abuse Monthly Round Up May 2025

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

PSR Case Reports March 2025

In the month of March 6 section 92 agreements and 3 final determinations came into effect. One of the agreements was made with an Obstetrician and Gynaecologist, one with a Radiation Oncologist, and four with GPs. Half of these practitioners were disqualified from billing certain items for a period. The three final determinations related to a GP, a dentist and an ophthalmologist respectively. These practitioners were all disqualified from billing certain items for a period. The maximum repayment across all practitioners for March was $700,000, which was enforced against a dentist. The findings included:

• The consent obtained from the patients’ parents did not correctly describe the services to be performed
• The medical record was inadequate
• The practitioner was sometimes not present
• Removal of calculus did not take place on the date of service
• Fissure seals were not performed on the date of service
• The service was not clinically indicated

These very troubling findings – billing for services not provided and billing for services when the practitioner was not even present - amount to fraud in our view, not inappropriate practice. The GP cases involved the usual litany of common findings – MBS requirements not met, services not clinically necessary, inadequate record keeping, and inadequate particularisation of templates. The agreement with the obstetrician/gynaecologist was interesting given it involved billing of the standard pregnancy planning and management item - 16590. The findings were:

• services billed under the practitioner’s provider number were not always personally provided by them
• for each service there was no record of the practitioner attending on the patient and no record the practitioner intended to be present at the time of birth
• some reviewed services did not contain a mental health assessment as required
• for some reviewed services, elements of MBS item 16590 were done during consultations where other professional attendance items were billed.

Item 16590 requires that all components of the item must be performed by a single doctor on a single patient on a single occasion of service. You can read more about that requirement here. You can access the March PSR case reports here.

FWA around the world

Private Cataract Clinics Investigated For NHS Fraud https://www.thetimes.com/uk/healthcare/article/private-cataract-clinics-investigated-millions-nhs-3fjz6qhpn The article is behind a paywall, but you can sign up and see a few articles for free. Our friend and colleague, Dr Simon Peck from Kirontech (who worked with us on the ABC Pain Factory program last year), was originally asked to look at cataract coding for BBC Newsnight and it has ballooned into a full-blown fraud investigation. For those who may not know, Dr Peck is a former anaesthetist and qualified fraud investigator who ran AXA International’s anti-fraud operations for decades. The back story is that the UK government has been using private providers for publicly funded cataract surgery, and it was noted that the number of cataracts coded as complex was increasing – dramatically – and was costing the NHS hundreds of millions of pounds, paid to five companies. Even the Royal College of Ophthalmologists in the UK commented that the changes could not be explained by changes in the population. The case was referred to the NHS Counter-Fraud Authority. We asked Dr Peck to comment. Here’s what he said: “The issue of private providers exaggerating the complexity of healthcare services for profit is well known. Whilst I have not reviewed medical records only the overall consolidated figures, the underlying pattern is one of the red flags we look for in data as it suggests that complexity of services may have been exaggerated. Our experience with healthcare worldwide is that paying bills on trust is unwise. All healthcare purchasers should have in place a process to monitor billing and trends and to investigate anomalies. Without such safeguards, it is inevitable that significant sums of money will be lost to fraud waste and abuse, and this is true in every country in which we have worked. The suggestion that payments may be made which could incentivise referrals of patients is also deeply concerning as there is a wealth of published evidence suggesting that such payments corrupt judgement. Many of these payments are illegal in the UK but this legal framework generally applies only to privately funded healthcare and enforcement is poor. CMA finalises changes for private healthcare - GOV.UK “ Optometrists were also on the take through various referral kickback schemes and weak regulation and enforcement were cited as contributing factors that allowed huge amounts of taxpayer’s money to be drained from the public purse. Nothing about these schemes was patient-focused and it’s all (sadly) very familiar. US Physician Convicted for Illegal Distribution of Opioids and Healthcare Fraud Conspiracies In the US, Dr Neil K. Anand, 48, of Pennsylvania, was convicted by a federal jury for health care fraud, wire fraud and unlawfully distributing controlled substances. Dr Anand was found to have defrauded a number of health insurers for “Goody Bags” of medically unnecessary prescription medications, which were dispensed to patients by pharmacies owned by Anand. In total, over $2.3 million was paid for the unnecessary Goody Bags. It gets worse, Dr Anand also distributed oxycodone inappropriately. He had unlicensed medical interns writing prescriptions for, what we call S8 drugs, but the scripts were pre-signed by Anand. Anand prescribed 20,850 oxycodone tablets for nine different patients, as part of the scheme. Once he got wind of the fact he had been caught he transferred around $1.2 million into an account in the name of his dad for the benefit of his minor daughter. The convictions added up. They include conspiracy to commit health care fraud and wire fraud, three counts of health care fraud, one count of money laundering, four counts of unlawful monetary transactions, and conspiracy to distribute controlled substances. He is scheduled to be sentenced in August and faces a maximum penalty of 130 years in prison. You can read the Department of Justice report here. International Law Enforcement Strike Against Multimillion-Euro Healthcare Fraud Network Involving a Doctor and a Medical Centre A criminal network who issued EUR 6.7 million in fake invoices for hearing aids has been dismantled by international law enforcement strikes in France and Germany, supported by Europol. The scheme involved fraudulent claims submitted for payment to France’s public health insurance system for hearing aids. The fraudsters set up fictitious hearing aid companies and secured accreditation and contracts with the French health insurance fund. They then used stolen patient details to issue false invoices that led to EUR 6.7 million in fraudulent reimbursements. The illicit funds were then channelled through dozens of shell companies across Europe. The French Gendarmerie carried out searches at the suspects’ residences, including a doctor’s home and a medical centre. The second phase of the investigation was in Germany. During the raids across France and Germany illicit funds were seized in the form of cash, luxury items, high-end vehicles, electronic devices and real estate. Europol supported this massive operation by helping trace the flow of illicit funds and mapping the laundering network behind the fraud. There is no information available on the next stages of the investigation yet, but we will keep watch. You can read the details here.