On 10/14/2010, the Brevard County State Attorney’s office filed a third degree felony against Leauntie S. Cole for making a false statement, or fact on Medicaid claim. She was arrested by law enforcement officers with the Attorney General’s Medicaid Fraud Control Unit, and later released. She is now facing 3rd felony criminal prosecution. Based upon the record, the fraud was for more than $300.00 and less than $20,000.00. Though she does not appear to have any criminal record in Brevard County
Now, let’s backup a few months to March 2010. Dr. Todd Scarbrough and his group had been accused of defrauding Medicare of millions of dollars, over a period of years. It took the Feds more a year to investigate the fraud. In March 2010, Dr. Scarbrough and his codefendant MIMA P.A., paid $12,000,000.00 plus interest to settle their civil case filed by the government. The settlement amount suggests the extent of the fraud. It appears that the good doctor Scarbrough was never arrested, was never criminally charged, and he entered into some “Integrity Agreement,” with the Dept. of Health and Human Services. A quick search confirms that he is now practicing oncology in Owensboro , Kentucky
So, here are my three questions of the day:
1. Did Ms. Cole fail to steal enough to avoid criminal prosecution?
2. Does Florida
3. Is our system dangerously corrupt?
ATTACHMENTS:
Caregiver arrested on charge of Medicaid fraud
Leauntie Shunina Cole, 26, of Cocoa
Cole was arrested by law enforcement officers with the Attorney General’s Medicaid Fraud Control Unit.
The investigation revealed that Cole provided personal care assistance services for Medicaid Waiver recipients. Cole presented falsified service logs to her employer, for reimbursement for services that were never performed, according to the Attorney General.
Cole is charged with one count of Medicaid provider fraud, which carries a maximum of five years in prison and a $5,000 fine.
Feds settle Medicare fraud case with MIMA
The U.S. Department of Justice said it has reached a tentative settlement with Brevard County
Following up on a whistleblower's complaint, federal agents spent more than a year investigating billing practices and medical records of Melbourne Internal Medicine Associates' cancer treatment center. The government filed its civil complaint in federal court in October and, in court records unsealed last week, lawyers asked for extra time to finalize a settlement agreement with MIMA. The terms of the settlement are not known.
"If the parties resolve this matter by settlement and the case is dismissed, the parties and the court will be saved substantial resources otherwise spent on discovery and trial," the government's lawyers said in asking for more time.
The government is seeking to recover losses from false Medicare claims submitted "as a result of the sustained fraudulent course of conduct of the defendants," MIMA and Dr. Todd Scarbrough (above), the former medical director of its cancer center. Scarbrough has since left the cancer center. Attempts to determine his whereabouts were unsuccessful. A call to his lawyer was not returned.
In its complaint, the government alleges the cancer center had "defrauded Medicare and TRICARE through various schemes designed to improperly inflate the claims that MIMA submitted on behalf of (the cancer center) to Medicare."
I might be able to provide some context on the MIMA story. I think you’re a lawyer, and if you are, there are some things you might even explain to me. For example, what’s the difference between civil fraud and criminal fraud? Our case was a civil case. I honestly don’t know why it never became criminal. But I have an idea. For example, I’m going to assume the fraud in the Leauntie S. Cole case you mentioned was demonstrably false. By that mean, a claim was filed, and no service was rendered. There was no instance of that in anything we did.
ReplyDeleteHere’s what I mean by that. Let’s take the first few paragraphs of the New York Times article. “But when one of Florida’s biggest physician practices submitted 62 claims for treatments by Dr. Todd J. Scarbrough, it turned out that he had not just been absent from the clinic — he had not even been in the country, according to federal officials.” Yes, I was out of the country when these patients were treated, and yes my name was on the bill for their treatments. But doctors take vacations all the time, and cancer patients can’t stop their treatment just because their doctor is on vacation. That’d be bad. But of course my partner was there to cover while I was gone, and I was there to cover while she was gone. But my name was on the bill for service. Had my partner’s name been on the bill… no fraud (I think… who knows… the government’s rules, regulations, and motivations are still deeply mysterious to me). It was just our standard operating procedure that if it was my patient getting treated, my name was always on the bill—it was that way for every doctor in our group. We thought that was appropriate. Come to find out, no, it wasn’t appropriate. The patients needed treatment, the patients got treatment, and there was a proper bill submitted… all except for the wrong radiation oncologist’s name on the bill. Fraud? You decide. I didn’t control what name was on the bill—we had a billing staff for that. And just being an employee (I was a medical director, not an administrator), I couldn’t really have had a say in how we billed, from a clerical standpoint, anyways.
“By not properly supervising technicians, as the government alleges, the doctors put patients at risk — and then tried to cover it up.” So what about that? In the “eyes of Medicare,” there are three supervision levels: general, personal, and direct. General means in the local geographic area. For example, I can provide general supervision from home. Personal means the doctor is in the same building as the procedure. And direct means the doctor is in the same room as the procedure… direct is the highest, most stringent level. So if there’s a procedure that requires direct supervision, and you only provide personal supervision, you can make the case that procedure was improperly supervised. For different procedures, there are different supervision levels. This is pretty complex stuff, but all doctors spend a considerable amount of time trying to keep up with whatever the government says is the proper supervision which should be administered for each procedure that’s out there.
When we started image guided radiation therapy (IGRT) in 2004, it was so new, there were no billing codes associated with it. We just loved the technology and thought it was the right thing to do. We were world leaders in it. We started doing it on every patient. But of course we weren’t billing for it, as there were no codes. Time passed and the technology caught on. There was a code which appeared in 2005, and we started billing for it. Due to some intricacies surrounding the code, there was no supervision level for the code. But we were always providing personal supervision for the treatment anyway, like we do for all our treatments. In January of 2006, the government switched to new code for the procedure. Unfortunately, we did not realize until summer of 2007 that the government had placed a direct supervision on the new code! The new supervision requirement meant we had to stand in the room with the patient, and irradiate ourselves—it was crazy and wrong. There are no direct supervision codes in radiation oncology at the time… except for this one. We tried some methods to satisfy the billing people that we were doing direct supervision, but they were never perfect. It was a very hot topic in radiation oncology, and very controversial, this whole direct supervision thing for IGRT.
ReplyDeleteSo fortunately Medicare changed IGRT to personal supervision (just in-office supervision) in January of 2008. But by that point I think our director saw blood in the water. He knew that technically we had been not providing the right supervision, although the wrong supervision we were providing had been made the right supervision as of 2008 and thereafter. He also knew we had done more IGRT than anybody else in the U.S. or the world, making our potential exposure financially quite huge.
As you probably know, these civil qui tam cases put all the power in the government’s hands. If the case goes to court and the defendant is found liable, the damages are tripled and there is an up to $11,000 per incident penalty. Given the amount of IGRT we had done, this number could have been as high as $100 million or more. So when MIMA got the chance to settle out of court for $12 million, it took it. Our former director Fred Fangman got his $2.6 million as his reward for exposing a process he’d been a part of since day one, the government got some of its money back (MIMA collected about $90 million from the government between 2003 and 2009 for radiation oncology treatments)… and everyone walked away satisfied I guess. I personally paid no money to the government. I never wanted to, and would have fought in court if I’d been made to pay anything.
You ask is our system dangerously corrupt? I don’t know. The government lawyers seemed so unethical to me. They sneered, belittled, and generally didn’t understand beans about radiation oncology. They criticized my use of emoticons in emails heavily—I’m being serious. The system may be corrupt, but maybe not on the side you think.