In 2021, the U.S. saw an increase in the prosecution of healthcare fraud schemes from the Department of Justice (DOJ). Despite the ongoing COVID-19 pandemic, efforts are increasing in the investigation, arrest, and eventual guilty verdict and plea of those individuals and organizations defrauding the system for personal gain. The following two case summaries detail two such stories.

Case 1

Manchester Pediatric Associates, LLC and its owner, Dr. Swathanthra Melekote, are on the hook for an almost $740,000 settlement following Medicaid fraud charges. Dr. Melekote submitted false Medicaid claims from 2015 to 2021. He was coding for maternal depression screens and vaccine administrations when no such action took place, in addition to upcoding a bill for medical service as a physician when it was a physician’s assistant or nurse practitioner who performed the service.

In the maternal depression screenings, Dr. Melekote failed to provide adequate documentation in the patient’s chart and attach numerical modifiers to the electronic claim for payment codes that his practice provided to DSS’s claim processor.

Case 2

In early December, a licensed physician and three other individuals were indicted in an international telehealth fraud and kickback scheme. This indictment alleges that all defendants used telehealth to generate prescriptions for compound medications and durable medical equipment, regardless of medical necessity. Between Tricare, Medicare, and private health insurance, the loss is upwards of $37 million.

Although the telehealth companies were not named, the claim is that the defendants would have prescriptions written for patients when there was never a provider-patient relationship established. They also claimed ‘nurses’ consulted with ‘patients’ before the prescription was written–when in reality, they outsourced a company in the Philippines who were not nurses (or in the healthcare system) and had never spoken with the alleged patients either. The defendants received all ‘patient information through paid marketing services as well.

White Collar Crime is a Target

White Collar Crime Does Not Pay in the Long Run

In a world of instant gratification and the urge to get rich quick, it’s important to think about the lasting ramifications these actions have. Not only does it ruin your reputation and discredit the years of school, training, and hard work, the effects go beyond just yourself. Your family and their way of life will become affected, and the divide between the general public and the healthcare system as a whole continues to widen. In 2021 alone, at least 43 individuals were indicted with healthcare fraud-related charges totaling over $1.1 billion.

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