The founder of an opioid medication manufacturer, Insys Therapeutics, is being prosecuted for fraud and racketeering based on allegations that he was pushing prescriptions of his company’s powerful painkillers. This case brings to light the dangers and complications of Medicare and Medicaid fraud.
Kickbacks to Overland Park physician part of the investigation
This case follows an investigation into the patient records of Overland Park physician Steven Simon. The physician served as the most highly paid spokesman for Subsys, a potent opioid manufactured by the pharmaceutical company. It is alleged that Dr. Simon and other physicians were receiving kickbacks for prescribing the drugs to their patients.
Insurance fraud part of the criminal investigation
According to reports, six former executives of Insys were indicted for using a speaking program to provide kickbacks to physicians for prescribing a new fentanyl spray approved only for breakthrough cancer pain. It is alleged that these executives encouraged physicians to prescribe the painkiller to patients who did not actually have cancer. They also allegedly helped the physicians to defraud insurers so that it appeared as though the patients had cancer.
Claims against Dr. Steven Simon
According to the investigation, Dr. Simon was the eighth-highest-paid national speaker for the company from August 2013 to December 2015. He received in excess of $200,000 in speaking fees, meals, and related travel expenses. He was also responsible for training other speakers to provide the same service for the pharmaceutical manufacturer. Dr. Simon was also the most highly paid Kansas physician in the speaking program.
Other Kansas physicians have been charged with fraud
Dr. Simon is not the first Kansas physician to be accused of health care fraud. A former Kansas City physician, 74-year-old Wayne Williamson, has been sentenced to prison for the second time for health care fraud. His latest sentence will last one year and three months in a federal prison. Back in 2010, Williamson was forced to surrender his medical license when he pleaded guilty to fraud, conspiracy to distribute Oxycontin, Percocet, and Xanax, among other related charges. He was sentenced at that time to three years in prison and was permanently banned from participating in Medicare or Medicaid programs.
The unfortunate reality is that Medicaid fraud and abuse, which violates Medicaid law, does happen and it costs billions of dollars each year in diverted funds that should have been used for legitimate health care services. Because of the fraud and abuse, the cost of Medicaid is higher, as is the risk of harm to patients who are unwittingly exposed to unnecessary medical procedures.
Medicaid fraud and Medicaid abuse
Medicaid fraud happens when someone knowingly misrepresents the truth in order to obtain unauthorized benefits. This type of fraud can be committed by patients as well as health care providers. Medicaid abuse, however, includes any practice that is inconsistent with acceptable economic, business or medical practices and that unnecessarily increase costs. Both types of misconduct violate Medicaid law.
Common examples of health care provider fraud
Medicaid fraud is not only seen in the actions of the patient. It can also be committed by health care service providers. Some of the most common examples of Medicaid fraud by health care providers which violates Medicaid law include billing for medical services not actually performed, submitting duplicate billing for the same service, submitting a false diagnosis, billing for more expensive services than were actually performed, receiving kickbacks for referring patients, billing for covered Medicaid services when a non-covered service was actually provided, ordering excessive or unnecessary tests, and prescribing medication that is not medically required.
Recognizing and reporting provider Medicaid fraud
There are several ways to recognize whether provider fraud is occurring with regard to your medical care. For one thing, whenever you obtain health care services, keep a record of the dates you receive those services and save the receipts and statements you obtain from providers. That way you can compare the dates and services listed in your records with the statements you receive from Medicaid.
If you have questions regarding Medicaid fraud or any other Medicaid planning or elder law matters, please contact the experienced attorneys at Gaughan & Connealy for a consultation. You can contact us either online or by calling us at (913) 262-2000. We are here to help!