What’s in the Doctor’s Bag?

36193662 - female doctor with money in his pocket a blue robe

The government loses tens of billions of dollars annually from a variety of fraudulent healthcare schemes. Upcoding, arguably one of the most popular methods used to siphon off healthcare funds, was the scam of choice for a Warren County, Kentucky physician who was recently convicted of healthcare fraud. (But, that wasn’t all he was up to. There were a few more illegal activities hiding in this doctor’s bag.)

Upcoding occurs when a claim is submitted using a code linked to a higher level of service than is actually provided. For example, let’s say that a person has a hairline fracture in their arm from a bad fall. A deceptive doctor could put a splint on the individual’s arm and submit a claim showing that instead of a splint, it was a hard cast. Later, another claim could be submitted showing the cast removal, when there was no cast to actually remove. (Deceptive docs probably figure that their billing procedures are unlikely to be audited, and if careful, they can fly under the radar.)

For approximately seven years, the Bowling Green area physician submitted fraudulent claims to multiple healthcare benefit programs, including Medicare and Medicaid. He coded office visits at a higher service rate, but provided a lower level service. (Looking on the bright side, I guess you could say that at least he provided a service. Some fraudsters bill for a service that they never provide. But, I digress.)  He got paid for the higher-level service, while also submitting claims for medically unnecessary spirometry tests (which show how well your lungs are working) and electrocardiogram tests (which show how well your ticker is working.)

And, as if that were not enough, he got into a heap of trouble by conspiring with others in his medical office to intentionally distribute and dispense Schedule II, III and IV controlled substances such as Methadone, Fentanyl, Hydrocodone, Clonazepam and Oxymorphone over three years. It’s important to note that none of the drugs were disbursed for legitimate medical reasons. (He was dealing drugs, plain and simple.)

The 66-year-old Bowling Green, Kentucky physician pleaded guilty to healthcare fraud, along with unlawful distribution and dispensing of controlled substances. He was sentenced to eight years of prison and ordered to pay restitution and court costs of $162,366.46. He must also pay a $17,500 fine and forfeit his medical license, which by the way, had been previously suspended. (Go figure. That doesn’t surprise me.)

Billing fraud not only has an impact on the medical insurance provider – such as Medicare and Medicaid – but, also on the patient who ends up with the wrong information on their medical record. (This could impact their ability to acquire insurance in the future.) If you suspect upcoding after checking your Estimate of Benefits (EOB), first contact your insurance carrier. Hopefully, they’ll correct the charge, but if not, pay attention to subsequent EOB’s to see if there is a trend. If so, contact your insurance provider immediately. For more tips on how to protect yourself from being a victim of government healthcare fraud, follow these tips.

 Today’s “Fraud of the Day” is based on an article entitled, Bowling Green doctor sentenced to 96 months in prison,” published by The Glasgow Daily Times on May 7, 2018.

BOWLING GREEN — A Warren County physician, Charles Fred Gott, was sentenced in U.S. District Court, before U.S. District Judge Greg N. Stivers, to 96 months’ imprisonment for multiple charges of unlawful distribution and dispensing of controlled substances and health care fraud, announced United States Attorney Russel M. Coleman.

Gott, 66, a formerly licensed physician, was initially indicted by a grand jury in Bowling Green on June 10, 2015. Today, Gott was sentenced in accordance with his plea of guilty, entered on Feb. 5, and ordered to pay restitution and court costs in the amount of $162,366.46, and forfeited his medical license, which had previously been suspended. Furthermore, Gott was order to pay a fine in the amount of $17,500.


Previous articleFraud On-the-Move
Next articleRubbed the Wrong Way
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.