A former Montana nurse practitioner was sentenced to five years in prison, followed by three years of supervised release, for falsely billing an insurance company approximately $62 million for vitamin B-12 injections. She received about $613,108 from the fraudulent claims, US Attorney Jesse Laslovich announced on January 17. The court also ordered her to pay restitution in the amount of $613,108 and allowed her to self-report to the US Marshals Service.
According to court documents, the defendant’s nursing license was suspended by the Montana Board of Nursing on April 1, 2022. Despite this, she continued to prescribe controlled substances using her own name and DEA registration number until June 2022. After being contacted by the DEA, she voluntarily surrendered her registration. However, she then began prescribing controlled substances using a friend’s name and DEA number, misrepresenting to her friend that her license was only on probation, not suspended. She used her friend’s registration to issue at least 28 prescriptions for controlled substances.
The government also alleged that the nurse practitioner submitted fraudulent claims to Blue Cross Blue Shield of Montana for 158 vitamin B-12 injections that never occurred, stealing $613,108 from the insurer. In August 2021, she began inflating the number of units for each vitamin B-12 injection, from one unit to 1,000, thereby increasing the payment per injection from about $4.88 to $4,880. After her license was suspended, she continued submitting backdated claims to Blue Cross Blue Shield of Montana, including fraudulent claims for $15 million per injection for a new patient in May 2022. In total, she billed the insurance company $62,310,000 in false claims.
Compliance Perspective
Issue
Healthcare fraud can be perpetrated by medical providers, company owners, patients, and others who intentionally deceive the healthcare system to receive unlawful benefits or payments. It is crucial that staff who provide skilled services understand what constitutes reasonable and necessary care, which should be based on a patient’s individual needs and abilities. Failure to report suspected fraud promptly can lead to citations, fines, and other sanctions. Additionally, staff should be well-informed about how to report suspicious billing practices. Professional licenses must be verified upon hire, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) should be checked monthly to ensure no current employees are on the list. The status of professional licenses should also be tracked regularly. Hiring or partnering with individuals or entities on the LEIE can result in civil monetary penalties (CMP).
Discussion Points
- Review and update policies and procedures to verify the status of professional licenses, ensuring they are not included on state or OIG exclusion lists. These policies should also address how to prevent and report false claims and suspicious billing practices.
- Train staff to follow proper protocols for verifying licenses and certifications at the time of hire and on an ongoing basis. Ensure that licenses remain up to date and unencumbered. Provide training for licensed personnel on their responsibility to maintain an active license and notify administration if their license is suspended, expired, or if they are added to the OIG LEIE or a state exclusion list. Additionally, train staff on what constitutes a false claim and how to report concerns and suspected violations.
- Periodically audit to verify the validity and timeliness of employee licenses and certifications. Ensure routine checks against the OIG LEIE are conducted. Address any negative findings immediately. Also, perform regular audits to ensure that staff understand the importance of identifying compliance and ethics concerns and are aware of their responsibility to report these concerns to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*