Deeper Than the Headlines Orthopedic Surgeon Receives 16 Month Prison Sentence for Health Care Fraud

Hello, everyone. This is CJ Wolf with Healthicity for another video on the series deeper than the headlines.
In this series of videos, we try to go a little bit deeper past those headlines that we often see either posted in a press release by the Department of Justice or maybe the OIG.
And today's topic is the conviction of an orthopedic surgeon.
So a few months ago, the surgeon was convicted of health care fraud, predominantly in the area of upcoding e and m codes. So a lot of you know that evaluation and management coding are those codes, office, for example, office outpatient visits or office new patients where you have multiple levels. And by choosing those highest level of codes, you receive more reimbursement, And so those services need to be warranted.
Well, it was, alleged in this case that the surgeon was upcoding, not performing some of the services that he was billing for in those upcoded claims and then would falsify the records to make it look like he had done all that work. Now what's interesting in this case is that just about a month ago, he was sentenced to sixteen months in prison and a year after prison of supervised, release.
So a lot of these stories that we share in the in in deeper than the headlines are civil cases where they're, financial settlements. This one was actually a conviction, criminal conviction, and the surgeon will be, serving time in prison, unfortunately.
So but what I thought was really interesting about this case is the tools that they used to identify this. And one of the things that they identified was that the surgeon was seeing anywhere from sixty patients to sometimes a hundred patients in one clinic day. That's a lot of patients. Theoretically, that's possible, but it starts to get into this realm of in this concept of impossible days, where it's just so so unlikely that that many patients are seen.
It it seems that something might be wrong, especially when that many patients are being seen in one clinic day and the higher level of codes are being reported, which usually, not always, but usually take a little bit more time. And so if if you did the math, and this is what some of the investigators did, they did the math based off of the schedule of when the surgeon was in the office and looked at all the patients and figured out how much time was there, and if there were no breaks, you know, and and and how many of us do no breaks. I guess that's theoretically possible.
But, these visits would have been two and three minutes long. And so and that's what, that's what they were thinking. And so they sent in undercover agents to act as patients.
So at least one that we know of, maybe more. But that's what I thought was really interesting is it's it's one thing, you know, when we do these coding reviews to look at the medical documentation and say, yes. This medical documentation equates to that code.
In this case, it probably would have equated to that code, but the problem is is that some of the things documented in the chart did not take place. So for example, when they sent in an undercover agent, this agent went in for shoulder pain from a shoulder injury and was seen six different times.
And in each of those times, it was just a very, very short visit, sometimes three minutes, sometimes five minutes. I think the longest was eleven minutes, four minutes. I though so it was in in this range of single digit minutes for these visits, and the undercover agent noted that no physical exam was done and no medical history was taken.
So and there was undercover video as well. So, there's it's hard to kind of argue that when, then the medical record shows that a physical exam is done or that some sort of history has been taken when the undercover agent knows that that that wasn't the case. And so I looked at the, court records and pulled the exhibit and witness list.
They were also calling for real patients as witnesses. They were on their witness list, probably to ask similar questions about what did this, surgeon do when you visited, how long were the visits, those sorts of things. And then as I mentioned, they were going to include the, witness of this undercover agent as one of the witnesses, in that trial as well as undercover video. There were a lot of other things, other documents, medical records, and office schedules, and clinic schedules, and those sorts of things that were included, on those exhibit lists. So pretty interesting case.
Be truthful in what you're documenting.
I know it's it's probably not common for, undercover agents to to go in as as patients, but I have seen other cases as well. I remember a case, in the northeast part of the country, and it was psychiatry. And those are time based codes where, you know, there's psychotherapy codes, and you have to do a certain number of minutes of psychotherapy.

[@ElizabethJohnson-qi2bo]

We should all examine our EOB's.

[@danrio8870]

Who do we report possible health Care fraud to who will actually conduct an investigation without blowing it?

[@starrystarrynight6281]

You also failed to mention he was the second highest physician of prescribing opioids.