As a physician you have taken an oath to serve your patients to the best of your ability. In the environment of healthcare it is very easy to commit fraud, whether it be intentional or unintentional, it happens. One way to make sure that you land on the radar for an audit is to just standard bill your patients for services rendered. There is nothing wrong with this practice but the caveat is that you have to have met the requirements needed to bill that code or service. Our fraudsters of the week come from an office in Texas with many cases of fraud. “Two who worked for Ex-NFL player turned doctor charged in fraud scheme” By Rissa Shaw for KWTX tells the tale.
According to the complaint, Sumerer and Morgan submitted and/or taught others to submit false health care claims between at least Jan. 2011 and March 2017.
“According to Latosha Morgan’s interview conducted on February 18, 2016, Melissa Sumerour instructed other office staff on billing procedures at the clinics,” the complaint states. “Physician A incentivized Melissa Sumerour and Latosha Morgan to maximize billing by offering a bonus if their respective clinics billed over $50,000 in a week.”
Morgan would receive 2 percent of the total amount billed, while Sumerour received 1 percent of the total billed to the Office of Workers’ Compensation Programs (OWCP), according to the complaint.
The document provides examples of inflated billing techniques.
One included changing billing codes on reports by indicating a physician, PA, or nurse practitioner “drafted the reports when in actuality non-medical clinic staff drafted the reports.”
Another example used was charging for drug tests that never took place.
“In or about December 2015, Physician A directed Melissa Sumerour and Latosha Morgan to bill for drug screen testing as if the clinic was conducting the testing when the clinics were only collecting specimens,” the complaint states.
It goes on to say, Sumerour taught Morgan and others to alter billing submitted by licensed medical professionals “to maximize billing for each service, and for services which did not occur.”
The complaint also said Sumerour and Morgan were billing for physical therapy services even though the clinics were not state-licensed to provide physical therapy, employed chiropractors to supervise physical therapy (which is against state and federal rules), and charge for physical therapy services which were not actually completed.
“Melissa Sumerour instructed Waco clinic office manager Person E and others to always bill five units of Therapeutic Activities, five units of Therapeutic Exercises, and four units of Manual Therapy, regardless of how much physical therapy the patient actually completed,” the complaint states. “This became known as the “5-5-4″ method of billing for physical therapy at the clinics.”
The complaint goes on to say, if the 5-5-4 method wasn’t used, Sumerour would adjust it before submission.
Over at six years, Sumerour, Morgan, and Benson cheated the government of more $5,900,000 in “false and fraudulentWomen who worked for Ex-NFL player turned doctor charged in fraud scheme claims” under the Federal Employees Compensation Act (FECA), a program that provides disability compensation benefits and payments for medical and rehab care for government employees injured on the job.
Multiple sources said Sumerour was part of a larger fraud scheme close to $30,000,000.
There are some serious instances of fraud being indicated in this article. If you have any questions about what happened you can contact us and one of our compliance specialists will help.
Thanks to KWTX and Rissa Shaw for Two who worked for Ex-NFL player turned doctor charged in fraud scheme“