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There are no balloons, handshakes or smiles when the Office of the Inspector General at the U.S. Department of Health and Human Services welcomes new physicians. There is instead a dry, fairly formal listing of “the five most important Federal fraud and abuse laws that apply to physicians”:

• False Claims Act
• Anti-Kickback Statute
• Physician Self-Referral Law (Stark law)
• Exclusion Authorities
• Civil Monetary Penalties Law

“As you begin your career, it is crucial to understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties” and more, the OIG says. The “more” includes fines, exclusion from Medicare and Medicaid and the loss of your medical license.

The OIG notes that it’s illegal to submit claims to Medicare or Medicaid that you know – or should know – are false or fraudulent. Penalties for violating the False Claims Act can mean fines of up to three times the amount the programs lost due to your false claims, plus $11,000 per claim you filed.

That means that if Doctor A filed 100 false Medicare claims for $1,000 each, the loss to that program would be $100,000. That means Doctor A could be fined up to $300,000, plus an additional $1,100,000 for his violations.

If Doctor A’s false claims were the results of kickbacks or were made in violation of the Stark law, there can be additional liability under the Anti-Kickback S

Federal prosecutors and law enforcement agents continue to show that they place allegations of Medicare fraud high on their list of priorities.

The U.S. Attorney’s office in the Western District of Michigan has announced the results of a Medicare fraud sting called “Operation Happy Clickers”, which has resulted so far in civil suits against three Michigan doctors and a guilty plea by a nurse practitioner. The name of the operation refers to the speed at which the involved medical professionals clicked on and approved prescriptions with little or no review. The prescriptions at issue were for various medical equipment and genetic tests that were not actually medically necessary.

The US Attorney’s Office said the actions resolved allegations of Medicare fraud that totaled $7.3 million.

Operation Happy Clickers follows nationwide arrests in 2019 and 2020 of what were called large-scale Medicare fraud schemes involving telemarketers, durable medical equipment supply company owners and cancer genetic testing labs.

In the recent Michigan case, telemarketers (often in overseas call centers) contacted Medicare recipients to sell them medically unnecessary tests and devices. The marketers then allegedly paid healthcare professionals to sign device and test orders. Then the telemarketers allegedly sold the approved orders to companies that supply devices and labs that perfo

The constantly evolving U.S. healthcare system imposes a variety of challenges on Michigan providers. Frequent changes to compensation models and billing regulations can result in billing errors that sometimes result in uncollected revenue and sometimes result in insurer overpayments and investigations of possible healthcare fraud.

The Association of Certified Fraud Examiners (ACFE) has on its website a list of health care provider fraud schemes compiled by veteran Certified fraud examiner and private investigator Charles Piper.

Certified fraud examiner and private investigator Charles Piper says that in almost every healthcare fraud investigation he’s conducted, he has found evidence that the provider submitted claims to Medicare, Medicaid or an insurance company for care that was never provided and that patient files had no supporting documentation.

Billing for services not rendered, he says, is “real easy money.”

Piper says though he understands that records can be lost or misplaced, “a pattern of billing for services and care with no supporting documentation is unacceptable and unlikely to be coincidental.”

In addition to examining documentation, fraud investigators conduct interviews with staffers and patients listed in claims.

While physician impersonation is pretty rare, this form of misrepresentation of th