Sophocles, who wrote such marvelous plays as Antigone and Electra, was quoted as saying, "I would prefer even to fail wth honor than to win by cheating." ln the face of the ongoing NFL deflategate investigation, it occurred to me that periodically l am asked if there is ever justification for a physician to participate in "a little fraud." The majority of the time, this relates to billing, coding, and reimbursement issues with payers.
ln a recent False Claims Act Qui Tam case, United States ex rel. Davis v. Centennial Pediatrics, P C., three relators came forward alleging fraud concerning a former colleague. The relators, all physicians and former employees of Centennial Pediatrics, alleged that Dr. Hamilton, through Centennial Pediatrics, upcoded bills that were submitted to the Tennessee Medicaid Program. He did this by billing comprehensive infant auditory screening exams when he actually performed less expensive and limited examinations. The relators also alleged that the Centennial Pediatric offices upcoded urinalysis testing by billing for urinalysis with a microscopic examination when a microscopic examination was not done. Finally, the complaint states that Dr. Hamilton and Centennial, in essence, unbundled the billing following the administration of immunizations to their patients. What this means is they provided patients a combination vaccine, and billed for each separate component, which is unlawful.
So, was this "a little fraud?” In fact, the concept does not exist. Although some fraud and abuse can be truly egregious, any fraud has the potential to impact patient safety, quality of care, and the financial success of federal and state programs. Dr. Hamilton pleaded guilty to a misdemeanor count of healthcare fraud and entered into a civil settlement. He has been excluded from participation in all federal healthcare programs for 20 years and will pay more than $1.6 million for violating the False Claims Act.
Fortunately, there are many individuals who understand that "a little fraud" does not exist. Quite often, they are relators who, through their attorneys, bring their concerns to the government to put a stop to this behavior. Since it is the right thing to do, my sincere appreciation to Drs. Davis, Hughes, and Morel for upholding their Hippocratic Oath to first do no harm.
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