Delaware PMR doc. 13million in cms fraud

[lobelsteve]

DC Physician Indicted for Almost $13M in Medicare Fraud

He allegedly submitted claims for procedures that were medically unnecessary, not provided, or both.

www.medscape.com

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[SageCraft]

I wasn't aware that you could be barred from injecting a specific area of the spine.

 

[SommeRiver]

What is the definition of "not medically necessary?" I get insurance denials that use the same terminology.

 

[Agast]

"In 2010, the Delaware Medical Board suspended Gooding's medical license for 6 months after one of his patients died after receiving an injection to treat pain, Becker's ASC Review reported. He was also barred from administering cervical block injections, the article stated. "


Reading in between the lines, he managed to kill someone with a cervical epidural steroid injection

 

[lobelsteve]

"In 2010, the Delaware Medical Board suspended Gooding's medical license for 6 months after one of his patients died after receiving an injection to treat pain, Becker's ASC Review reported. He was also barred from administering cervical block injections, the article stated. "


Reading in between the lines, he managed to kill someone with a cervical epidural steroid injection

Don’t assume CESI. There was a doc in Atl that killed with RF. Missed the waist, found opposite side of cord.

 

[hyperalgesia]

Don’t assume CESI. There was a doc in Atl that killed with RF. Missed the waist, found opposite side of cord.

Lemme guess, heavy sedation?

 

[painfree23]

I mean I’m sure he didn’t mean to kill the patient. We don’t know the details? Wrong med injection? Wrong location? Hematoma? Infection? I mean all our consents state the risks are bleeding , infection, worsening pain, paralysis and death. I mean if one of these lead to the death, you can’t say they weren’t warned of the risk?

 

[hyperalgesia]

I mean I’m sure he didn’t mean to kill the patient. We don’t know the details? Wrong med injection? Wrong location? Hematoma? Infection? I mean all our consents state the risks are bleeding , infection, worsening pain, paralysis and death. I mean if one of these lead to the death, you can’t say they weren’t warned of the risk?

It's not usually one complication that gets you in trouble. It's usually a pattern with one final event of gross negligence.

 

[lobelsteve]

I mean I’m sure he didn’t mean to kill the patient. We don’t know the details? Wrong med injection? Wrong location? Hematoma? Infection? I mean all our consents state the risks are bleeding , infection, worsening pain, paralysis and death. I mean if one of these lead to the death, you can’t say they weren’t warned of the risk?

In GA case it was an impaired practitioner.

 

[SommeRiver]

Yall are talking about pt death but no one cares about the fact the crimes include procedures that weren't "medically necessary?" That should cause everyone here to shudder. I got this all the time from insurance companies for procedures that are 100% legit.

Did a TFESI 3 weeks ago on a guy with severe stenosis. Didn't work, not even for 4 hrs. Pain is back, buttock, and hamstrings. I put in for MBB bc he has severe facet dz with synovitis...Denied bc it wasn't medically necessary. Giant facets loaded with fluid.

Not medically necessary...but I am certain no one would bat an eye if I put him on oxycodone, Soma, Ambien, and Valium.

 

[epidural man]

Yall are talking about pt death but no one cares about the fact the crimes include procedures that weren't "medically necessary?" That should cause everyone here to shudder. I got this all the time from insurance companies for procedures that are 100% legit.

Did a TFESI 3 weeks ago on a guy with severe stenosis. Didn't work, not even for 4 hrs. Pain is back, buttock, and hamstrings. I put in for MBB bc he has severe facet dz with synovitis...Denied bc it wasn't medically necessary. Giant facets loaded with fluid.

Not medically necessary...but I am certain no one would bat an eye if I put him on oxycodone, Soma, Ambien, and Valium.

What would happen if you did the procedure, the patient paid cash, he got better after RFA, then he took his insurance to small claims? I suspect no judge would side with insurance.

My guess is if lots of patients successfully did this, insurance may change some things.

 

[Ducttape]

somme - didnt the insurance give reasons for why it is not considered medically necessary?

read those forms, or have your secretaries call to find out.

typically, it will be something like "MBB are not medically necessary for radicualr back pain".

to epidural's point, my guess is small claims court would not rule in anyone's favor, if there were prepublished reasons that the insurance gave for denial.


with regards to the article:

Gooding allegedly knew that the injections were not provided. To disguise his scheme, he allegedly falsified medical documents to make it appear as if the purported medical services billed to Medicare were medically necessary.

he was indicted, Aug 2. so i cant find the case or the final legal briefings.

District of Columbia Physician Indicted for Alleged Role in $12.7 Million Health Care Fraud Scheme

A physician with a practice in the District of Columbia was charged in an indictment unsealed today for his role in an alleged $12.7 million health care fraud scheme to submit fraudulent claims to Medicare for complicated medical procedures he never provided.

www.justice.gov

but... while looking around, i found this as a reminder that we need to keep doing what we are doing, even if patients complain about UDS, frequent follow up, etc.

United States Files Suit Against Montgomery County Psychiatrist for Alleged Improper Opioid Prescribing

www.justice.gov

got off easy in a way - lost license and ability to prescribe, but it was based on only 2 patients

 

[cowboydoc]

What would happen if you did the procedure, the patient paid cash, he got better after RFA, then he took his insurance to small claims? I suspect no judge would side with insurance.

My guess is if lots of patients successfully did this, insurance may change some things.

Great idea, but probably not very cost effective for most patients.

 

[thecentral09]

thread hijack!
Do most of you attempt MBB for axial pain with movement on patients with severe central stenosis? I have found my outcomes to be very underwhelming, and when severe central stenosis is present (even without neurogenic claud), I have found a hard time getting people better with RFA (although severe facet degeneration present)

 

[callmeanesthesia]

thread hijack!
Do most of you attempt MBB for axial pain with movement on patients with severe central stenosis? I have found my outcomes to be very underwhelming, and when severe central stenosis is present (even without neurogenic claud), I have found a hard time getting people better with RFA (although severe facet degeneration present)

I try it too but I agree, results are underwhelming. Still, I’d rather exclude the facets before sending them to a surgeon because even if you can spare 1/4 of them surgery it’s worth it (and I think the success rate is definitely higher than that). If axial back pain and no red flags I do MBBs without MRI, and then get MRI to look for stenosis if MBB/RF fails.

 

[SommeRiver]

This gentleman is 77 yo and would require probably L2-5 fusion. It isn't just severe L4-5 spinal and foraminal stenosis; it is basically up/down stenosis and the same with the facets. I think those pts at least deserve an attempt at SOME improvement with MBB/RFA.

 

[SommeRiver]

Ducctape - Not medically necessary bc of stenosis. Problem is the epidural failed, and he's miserable and I don't feel good about sending him for a huge reconstruction.

 

[RM38]

Back to original issue. I did fellowship in that area and heard about what I think was likely this incident from our PD. If I remember correctly he is a non-fellowship trained PM&R guy that went to a couple of weekend courses and then did a stellate on somebody relatively soon after the course. The staff then rolled the patient into a recovery area and left them there unchecked for something like 30 mins. Not sure if sedation was involved or not. When they finally went back in the patient was already dead. DE actually passed a law due to this that I believe makes you credential as a level 2 surgery center to do procedures in the office.

Also I agree about trying MBB in severe stenosis if patient has facet mediated component to pain. Usually I do this on people whom have no weakness, are unsure about surgery or have other medical reasons why a fusion wouldn't be such a good idea.

 

[hyperalgesia]

What would happen if you did the procedure, the patient paid cash, he got better after RFA, then he took his insurance to small claims? I suspect no judge would side with insurance.

My guess is if lots of patients successfully did this, insurance may change some things.

I doubt it. "Not medically necessary" is the generic phrase but I'm sure the rationale is spelled out in the LCD of the policy that the patient purchased. Even if the LCD is absurd from our standpoint, I suspect that legally it's treated like the "terms and conditions" of other products.

Besides, after all that, the best you're gonna hope for is the 1000 or whatever for the RFA.

I think we need to take the gloves off when it comes to talking about specific insurance companies and plans with our patients. Why are we afraid to tell a patient their insurance is "not medically necessary" but this other insurance company is much better?

 

[BobBarker]

Sure, I tell patients all of the time to ditch Medicare advantage for Medicare with Mutual of Omaha or aarp supplement. Also tell them Coventry won’t let them have a vflex but Humana will.

 

[pmrmd]

Ducctape - Not medically necessary bc of stenosis.

You will see the exact wording in the indications for facet intervention that the patient doesn’t have other findings at that level that could be the cause of the pain.

 

[Ducttape]

so, what I have done as a "workaround" is to see the patient again, and document (if appropriate) that >60% of his back pain is axial, and that he has facet arthropathy on the MRI imaging, then copy the MRI and highlight wherever it says "spondylosis" or "facet arthritis/arthropathy/hypertrophy". I specifically state that "the leg pain currently is not as problematic as the axial back pain".

oh and all the usual gobblygook about worse with extension/rotation/failed physician directed home exercise program yada yada...


if it is severe spinal stenosis and they failed everything else barring fusion, send him to your least interventional surgeon, then ask for stim trial.... I mean major surgery on someone so old?if it takes a year to recover, and hes 77...

 

[callmeanesthesia]

so, what I have done as a "workaround" is to see the patient again, and document (if appropriate) that >60% of his back pain is axial, and that he has facet arthropathy on the MRI imaging, then copy the MRI and highlight wherever it says "spondylosis" or "facet arthritis/arthropathy/hypertrophy". I specifically state that "the leg pain currently is not as problematic as the axial back pain".

oh and all the usual gobblygook about worse with extension/rotation/failed physician directed home exercise program yada yada...


if it is severe spinal stenosis and they failed everything else barring fusion, send him to your least interventional surgeon, then ask for stim trial.... I mean major surgery on someone so old?if it takes a year to recover, and hes 77...

You can also document that the pain “refers” rather than “radiates” down the leg, especially if it’s not below the knees.

 

[SommeRiver]

I do all that...