Warning: Medicare/caid Billing Confusion May Lead to Jail Time

All health care providers are under serious scrutiny, that is, if they take Medicaid. In Atlanta, GA, a dentist, Dr. Oluwatoyin Solarin was sentenced to a year and six months for filing false claims worth nearly $1 million. She pled guilty, and, I would assume, she had an attorney who recommended that she plead guilty. But were her claims actually false? Did she hire a criminal attorney or a Medicaid attorney? Because the answers could be the difference between being behind bars and freedom.

Dr. Solarin was accused of billing for and receiving payments for dental claims while she was not at the office. U.S. Attorney John Horn stated that “Solarin cheated the Medicaid program by submitting fraudulent claims, even billing the government for procedures she allegedly performed at the same time she was out of the country.”

I receive phone calls all the time from people who are under investigation for Medicare/caid fraud. What spurred on this particular blog was a phone call from (let’s call him) Dr. Jake, a dentist. He, similar to Dr. Solarin, was under investigation for Medicaid fraud by the federal government. By the time Dr. Jake called me, his investigation was well on its way, and his Medicaid reimbursements had been suspended due to credible allegations of fraud for almost a year. He was accused of billing for and receiving payments for dental services while he was on vacation…or sick…or otherwise indisposed. He hired one of the top criminal attorneys, who advised him to take a plea deal for a suspended jail sentence and monetary recompense.

But, wait, he says to me. I didn’t do anything wrong. Why should I have to admit to a felony charge and be punished for doing nothing wrong?

I said, let me guess, Jake. You were the rendering dentist – as in, your NPI number was on the billed claim – but you hired a temporary dentist to stand in your place while you were on vacation, sick, or otherwise indisposed?

How did you know? Jake asks.

Because I understand Medicaid billing.

When my car breaks down, I go to a mechanic, not a podiatrist. The same is true for health care providers undergoing investigation for Medicare/caid fraud – you need a Medicare/caid expert. A criminal attorney,most likely, will not understand the Medicare/caid policy on locum tenens. Or the legal limitations of Medicaid suspensions and the administrative route to get the suspension lifted. Or the good cause exception to suspensions.

Don’t get me wrong, I am not advocating that, when under criminal, health care fraud investigation, you should not hire a criminal attorney. Absolutely, you will want a criminal attorney. But you will also want a Medicare/caid attorney.

What is Locum tenens? It is a Latin phrase that means temporary substitute. Physicians and dentists hire locum tenens when they go on vacation or if they fall ill. It is similar to a substitute teacher. Some days I would love to hire a locum tenens for me. When a doctor or dentist hires a temporary substitute, usually that substitute is paid by the hour or by the services rendered. If the payor is Medicare or Medicaid, the substitute is not expected to submit the billing and wait to be reimbursed. The substitute is paid for the day(s) work, and the practice/physician/dentist bills Medicare/caid, which is reimbursed. For billing purposes, this could create a claim with the rendering NPI number as Dr. Jake, while Dr. Sub Sally actually rendered the service, because Dr. Jake was in the Bahamas. It would almost look like Dr. Jake were billing for services billing the government for procedures he allegedly performed at the same time he was out of the country.

Going back to Dr. Jake…had Dr. Jake hired a Medicare/caid attorney a year ago, when his suspension was first implemented, he may have be getting reimbursed by Medicaid this whole past year – just by asking for a good cause exception or by filing an injunction lifting the suspension. His Medicaid/care attorney could have enlightened the investigators on locum tenens, and, perhaps, the charges would have been dropped, once the billing was understood.

Going back to Dr. Solarin who pled guilty to accusations of billing for services while out of the country…what if it were just a locum tenens problem?

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on February 17, 2017, in Administrative Remedies, Audits, Credible Allegations of Fraud, Criminal Medicaid Fraud, Dental Medicaid Providers, Dentistry Services, Doctors, False Claims, False Claims Act, Federal Government, Federal Law, Fraud, Gordon & Rees, Health Care Providers and Services, Injunctions, Knicole Emanuel, Lawsuit, Legal Analysis, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Advocate, Medicaid Attorney, Medicaid Audits, Medicaid Fraud, Medicaid Providers, Medicaid Reimbursement, Medicaid Reimbursements, Medicaid Services, Medicare, Medicare Audits, North Carolina, Physicians, Preliminary Injunctions, Uncategorized and tagged , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 1 Comment.

  1. Michael W Davis, DDS

    Whaaaa??? A doctor hires a locum tenens dentist, while on sick leave, vacation or whatever, & bills through his (her) same credentialing numbers? That’s asking for problems.

    I don’t care if it’s dental Medicaid or insurance. Each providing doctor MUST have appropriate credentialing & billed through their individual specific numbers. Currently, a big focus of HHS-OIG is examination for billings through non-credentialed providers or those disbarred from the Medicaid program. HHS-OIG openly states this in their public distribution material. It’s not brain surgery. Don’t do it!

    Prior to hiring a locum tenens or temp agency dentist, your responsibility is to do a due diligence on their credentialing. If not, it could place your butt in a sling. Ignorance of the law is not a valid excuse & these rules make common sense.

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