Tele-fraudster

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22573990 - man is laying on sofa and talking by phone with bandage on leg

Telemedicine is credited with helping to improve how healthcare is delivered. Some of the benefits include fewer hospital admissions and re-admissions, improved commitments to following recommended courses of treatment and faster recovery for patients. It sounds like a win-win situation until you consider today’s fraudster, a Tennessee-based nurse practitioner, who used telemedicine to commit healthcare fraud. She was one of seven who are charged with bilking TRICARE – the military’s health insurance provider – out of more than $65 million.

Fraudsters are always looking for ways to take something that was meant for good and use it for their own gain. The Tennessee woman in today’s fraud article is no different. She conducted bogus “telemedicine” evaluations that led to very expensive prescriptions for compounded drugs. Prescription recipients were recruited by co-conspirators, who targeted Marines and their dependents in the San Diego area. Investigators found that the specialized medicine was prescribed to a network of Southern California Marines who agreed to participate in a medical study. (Each Marine was paid between $100 and $300 a month to talk to docs over the phone for a telemedicine exam.)

Patient information for willing participants was sent to a Tennessee medical clinic where the nurse practitioner’ worked. She called the referred TRICARE beneficiaries and recommended that they receive prescriptions for compounded medications even though the patients were not examined in person. (While TRICARE does pay for telemedicine consultations, they must be held in places such as a doctor’s office, not at home.)

Doctors who worked for the same employer signed off on the recommended prescriptions, which were then sent to specific pharmacies controlled by the co-conspirators. Prescriptions were filled, then billed to Medicare at ridiculous prices. Just to show you how ridiculous, consider that TRICARE was billed $65,679,512 for 4,442 prescriptions. (Try not to choke. That’s $14,786 per prescription.)

 As mentioned at the beginning of the fraud blog, the 52-year-old nurse practitioner from Tennessee was one of seven others involved in the healthcare fraud scheme. Her co-conspirators included a physician and two chiropractors. (Two of the doctors and one Marine were also convicted of healthcare fraud.) The nurse practitioner faces a decade behind bars and substantial fines. The owners of the medical practice where the nurse worked also owned one of the pharmacies involved in the scheme. Their cases are pending.

This case is just one of many others connected to more than 600 people charged in a nationwide healthcare fraud investigation involving more than $2 billion in false billings. These schemes billed Medicare, Medicaid and other public and private insurers for treatments that were not medically necessary, and in many cases, not provided to patients at all. Congrats to the Department of Justice for declaring war on healthcare fraud. Let’s hope that the word trickles down to other fraudsters considering taking advantage of government healthcare programs. (It’s not going to end well for you. Make sure you tell all your fraudster friends.)

Today’s “Fraud of the Day” is based on an article entitled, “Nurse practitioner pleads guilty in $65 million prescription fraud involving San Diego Marines,” published by San Diego Union Tribune on November 27, 2018.

A nurse practitioner pleaded guilty Tuesday in federal court in San Diego to taking part in a kickback scheme that used San Diego County Marines to defraud the military’s health insurance provider out of more than $65 million.

Candace Michelle Craven, 52, became the fourth of seven defendants charged in the scheme to plead guilty when she admitted to conducting sham “telemedicine” evaluations that resulted in the issuance of pricey prescriptions through the TRICARE system to patients she never saw or examined in person.

 

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.