Fraud, Waste and Abuse Monthly Round Up June 2025

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

PSR Case Reports April 2025

In the month of April 3 section 92 agreements and 6 final determinations came into effect. Two of the agreements were made with General Practitioners and one with a Plastic Surgeon. All of these practitioners were disqualified from billing certain items for a period. The six final determinations related to two chiropractors and four GPs, all of whom were also disqualified from billing certain items for a period. It is quite unusual to see full disqualification from all MBS billing, but this month one GP was fully disqualified from rendering MBS item services for 24 months and another was fully disqualified for 3 months. The maximum repayment across all practitioners for March was $537,000, which was enforced against a GP. This month the troubling findings against the various practitioners were extensive including:

• MBS requirements were not met.
• Medical records were inadequate.
• Clinical input was insufficient or inadequate.
• Services were not clinically relevant.
• For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS items such as 23, 721, 723, 732 and 2713.
• Templates were not sufficiently particularised.
• The MBS time requirements were not met.
• CT scans and pathology studies were not clinically relevant.
• Upcoding – billing for a longer or more complex service than was provided.
• Some of the procedures billed by the plastic surgeon were not clinically justified.

It was a litany of poor behaviour that even extended to sharing provider numbers – which is absolutely prohibited. The list of services that were found to have breached the requirements for one GP included all of this:

• 23
• 721
• 723
• 732
• 2700 (attendance to prepare a GP mental health treatment plan (GPMHTP) – 20 to 40 minutes)
• 5000 (after-hours attendance – for a straightforward problem)
• 5020
• 31357 (excision of non-malignant skin lesion – less than 6mm in diameter)
• 31360 (excision of non-malignant skin lesion – at least 6mm in diameter)
• 31362 (excision of non-malignant skin lesion – less than 14mm in diameter)
• 31364 (excision of non-malignant skin lesion – at least 14mm in diameter)
• 91809 (phone attendance – less than 20 minutes)
• 2089Y (temazepam 10 mg tablet, 25)
• 2335X (pregabalin 75 mg capsule, 56)
• 3162K (diazepam 5 mg tablet, 50), and
• 8455B (tramadol hydrochloride 50 mg capsule, 20).

This GP was suspended from not only MBS billing for 24 months, but also from prescribing, effectively ending his/her ability to continue practicing. This month’s cases serve as a salient reminder of Medicare billing basics. If you follow this motto, you won’t go too far wrong. If it’s not clinically necessary DON’T BILL IT. If you bill it, you must meet ALL requirements of EVERY item you bill EVERY TIME you bill it – NO EXCEPTIONS. And if it wasn’t written down it didn’t happen – it’s the law. You can access the April PSR case reports here.

FWA around the world

$118M in Fraudulent Healthcare Claims by a Texan Rheumatologist who Falsely Diagnosed and Treated Patients for Two Decades Dr Jorge Zamora-Quezada, 68, was sentenced to 10 years in prison and three years of supervised release for falsely diagnosing patients with rheumatoid arthritis and proceeding to cause them to have unnecessary tests and treatments. He faked their records and submitted fraudulent claims for payment. Dr Zamora-Quezada funded a lavish lifestyle for two decades by “traumatizing his patients, abusing his employees, lying to insurers, and stealing taxpayer money.” His conduct was described as depraved, abusing both his patient’s trust and public resources. Other rheumatologists who testified said they saw hundreds of patients previously diagnosed with rheumatoid arthritis by Zamora-Quezada who did not have the condition. Worse, the powerful medications he prescribed caused terrible side effects in some patients including “strokes, necrosis of the jawbone, hair loss, liver damage, and pain so severe that basic tasks of everyday life, such as bathing, cooking, and driving, became difficult. As one patient testified, “Constantly being in bed and being unable to get up from bed alone, and being pumped with medication, I didn’t feel like my life had any meaning.” One mother described how she felt that her child served as a “lab rat,” and others described abandoning plans for college or feeling like they were “living a life in the body of an elderly person.”” He was also found to have been an abusive and manipulative employer. He fired anyone who challenged him and chose to employ vulnerable people whose visas could be cancelled if they lost their job. You can read the Department of Justice report here. Missouri Man Pleads Guilty to Multimillion-Dollar Medicare Fraud Conspiracy Jamie P. McNamara, 49, pleaded guilty to orchestrating a scheme to defraud Medicare by unlawfully billing millions of dollars in claims for cancer genetic testing and cardiovascular genetic testing. McNamara owned and operated genetic testing labs that obtained doctors request forms for these tests. Aggressive telemarketers and call centres were used to induce Medicare beneficiaries to agree to have them, even though they were completely unnecessary. Orders for the tests were signed by doctors who neither consulted nor treated the patients. McNamara paid illegal kickbacks and bribes to the doctors to get the request forms. There were also sham contracts, and a range of other lies used to disguise his criminal activity. In approximately one and a half years McNamara had submitted over $174 million in claims and received over $55 million in reimbursements. He will be sentenced in September and faces up to 10 years in prison. You can read the details here. Now over to the UK. Four men jailed for £6m bribery and corruption against NHS Scotland On 5 June 2025, two former NHS employees, Alan Hush and Gavin Cox, were sentenced to eight years and six years jail respectively. Adam Sharoudi was jailed for eight years, and Gavin Brown was given a seven-year prison sentence. They perpetrated a combined 29 years of fraud, bribery, and corruption against NHS Scotland. Between 2010 and 2017, Hush and Cox accepted bribes and other incentives worth £100,000 to provide sensitive information that led to the awarding of NHS contracts worth £6 million. The investigators found that many of the incentives were later paid for by the NHS through false, inflated or duplicated invoices. More than 4000 items of evidence were collected and over 250 witnesses were interviewed in this large-scale investigation. The tens of thousands of text messages and emails that were reviewed uncovered deliberate acts to divert or manipulate NHS funds for personal gain at the expense of patient care and public trust. This has been described as a landmark case for NHS Scotland Counter Fraud Services and was of particular significance because it highlighted the growing importance of digital forensic work in fraud prosecutions. You can read the details here.