Resources Summarize Key Health Care Fraud Rules

Physician health care fraud prosecutions and convictions of physicians like Arizona physician Linh Cao Nguyen, M.D. drive home the need for all physicians to ensure their understanding and ability to defend their compliance with federal and state healthcare fraud laws. This includes, but it’s not limited to proper coding and billing for the use of mid-level in the delivery of care. Physicians and other prescribers should review a recently released resource to get a basic overview of these federal healthcare fraud rules.

Nguyen Health Care Fraud Plea For Billing Delegated Care As Physician Provided

One of literally thousands of physicians and other prescribers prosecuted by federal prosecutors for health care fraud, Nguyen pleaded guilty on March 19, 2024, to Health Care Fraud. Nguyen’s sentencing is scheduled for May 28, 2024, before United States District Judge John C. Hinderaker.

Nguyen admitted that for years, he engaged in a scheme to defraud various health care benefit programs, including Medicare, TRICARE, AHCCCS, Blue Cross Blue Shield, and UnitedHealthcare.

Court documents charged the fraudulent claims generally identified a medical doctor as the treating provider when, in fact, another provider such as a nurse practitioner, social worker, unlicensed psychology intern, or wound care nurse provided the service independently. By billing the medical service as if it were provided by a physician, Nguyen falsely inflated the amount his company was to be paid for the service.

Through these prohibited practices, Nguyen confessed to knowingly causing submission of thousands of false billing claims.Nguyen falsely created patient records to conceal and avoid detection of his fraudulent billing scheme.

Nguyen admitted the loss he caused was at least $3.7 million dollars. He agreed to pay restitution to the private insurance companies totaling over $1 million.

A conviction for Health Care Fraud carries a maximum penalty of 10 years in prison and a $250,000 fine.

Learn Basics From HHS Physician Health Care Fraud & Abuse Educational Resources

Along with ensuring that billing for care properly reflects the identity and legal capacity of the caregiver, physicians also have to negotiate a number of other federal healthcare laws.

The Department of Health and Human Services (“HHS”) Office of Inspector General (OIG) has created the educational materials listed below to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse:

• A Roadmap for New Physicians (PDF), which is a booklet for physicians’ self-study;
• A companion PowerPoint presentation; and
• The speaker note set that accompanies the PowerPoint and a narration of the speaker notes to accompany the PowerPoint slides.

The presentation summarizes the five main Federal fraud and abuse laws (the False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Statute, and the Civil Monetary Penalties Law) and provide tips on how physicians should comply with these laws in their relationships with payers (e.g., the Medicare and Medicaid programs), vendors (e.g., drug, biologic, and medical device companies), and fellow providers (e.g., hospitals, nursing homes, and physician colleagues).

Physicians and another prescribers are encouraged to use these resources to help build their awareness of these rules as they relate to their practices. If any questions exist, physicians are encouraged to seek the advice of legal counsel to confirm their compliance.

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If you need have questions or need assistance with this or other cybersecurity, health, benefit, payroll, investment or other data, systems or other privacy or security related risk management, compliance, enforcement or management concerns, to inquire about arranging for compliance audit or training, or need legal representation on other matters,  contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

About the Author 

Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35 plus years of employee benefit, managed care and other health and insurance industry, workforce and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Co-Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee and Vice-Chair Elect of its International Employment Law Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, and Chair of the ABA Intellectual Property Section Law Practice Management Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading-edge work, scholarship and thought leadership on heath benefit and other healthcare and life science, managed care and insurance and other workforce and staffing, employee benefits, safety, contracting, quality assurance, compliance and risk management, and other legal, public policy and operational concerns in the healthcare and life sciences, employee benefits, managed care and insurance, technology and other related industries. She speaks and publishes extensively on these and other related compliance issues.

Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, life sciences, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. Author of a multitude of highly regarded publications on HIPAA and other medical record and data privacy and scribe for the ABA JCEB Annual Meeting with the HHS Office of Civil Rights, her experience includes extensive involvement throughout her career in advising health care and life sciences and other clients about preventing, investigating and defending EEOC, DOJ, OFCCP and other Civil Rights Act, Section 1557 and other HHS, HUD, banking, and other federal and state discrimination investigations, audits, lawsuits and other enforcement actions as well as advocacy before Congress and regulators regarding federal and state equal opportunity, equity and other laws. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

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