Doc Robbin’

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Does stealing from insurance carriers to keep an ailing medical practice afloat really classify as ”Robin Hood”-type behavior? According to The Record, a judge who compared a New Jersey doctor to the English folk hero also sentenced the offender to multiple years in prison, after he was found to have fraudulently billed public and private insurance providers more than a quarter of a million dollars for patient office visits that never happened. (While the judge did not accuse him of acting solely out of greed, she did hold him accountable for actions that violated his position of trust as a physician.

In a medical service billing scheme that lasted more than a decade, the Bergen County doctor submitted claims to Medicaid, Medicare and private insurance carriers for medical tasks that could have involved office visits, but did not. In addition to writing prescriptions and authorizing refills that he later misrepresented to insurers, he regularly inserted into patient records false information, like blood pressure readings, to support claims of nonexistent office visits. Even worse? He pressured staff members to do the same, even though at least four of them warned him of the ethical and legal repercussions of such actions. (Note to potential whistleblowers: you blew it.)

But one astute patient noticed that their insurer had been billed for a prescription incorrectly listed as having been written during an office visit. The patient tipped off the insurer, who then attempted to audit the doctor’s records. But when the dodgy doctor realized what was going on, he intentionally attempted to manipulate the audit’s results by destroying patients’ original medical records and replacing them with fake ones. (The cover up always makes the crime so much worse.)

Soon after, the doctor’s shady rule over Sherwood Forest came to an abrupt end, in court. While the doctor’s defense attorney called him ”selfless with his time” and just a ”bad business person,” the presiding judge noted that he did not apologize or show remorse. She went on to sentence him to 37 months in prison and ordered him to pay back $280,000 to the insurance carriers he defrauded.

Defrauding insurance carriers is wrong and illegal, but to do so by falsifying patient records puts people’s lives at risk. What if another doctor went on to base a critical medical decision on false information? The legendary Robin Hood stole to help the masses. This doctor stole his patient’s trust.

Source: Today’s ”Fraud of the Day” is based on, ”Bergen County doctor sentenced to over 3 years in insurance fraud case,” written by Peter J. Sampson and published by The Record on March 14, 2016.

A Bergen County doctor was sentenced Monday to more than three years in prison by a judge who said his decision to bill insurers for patient office visits that never happened reminded her of Robin Hood.

During a two-hour hearing in Newark, U.S. District Judge Esther Salas flatly rejected a request by Albert Ades, 61, of Englewood to be placed on probation with a period of home confinement and community service.

Instead, she sentenced Ades to 37 months behind bars and ordered him to pay $280,000 in restitution to the public and private insurance carriers that were defrauded by his scheme.

Ades, a family medicine doctor with offices in Cresskill and Little Falls, was arrested 13 months ago and charged with fraudulently billing Medicare, Medicaid and private health care insurance companies for face-to-face physician office visits that never occurred.

Ades wrote prescriptions, authorized refills, or performed other tasks, without seeing his patients on the billed dates. He also altered, and directed staff at his medical practice to alter, patients’ medical charts by inserting fabricated blood pressure readings, among other notations, to make it appear as if patients had visited his office on the dates in question.

When one insurer began an audit after a patient reported Ades for billing prescription refills as office visits, Ades shredded original medical records and created bogus records to obstruct the audit, authorities said.

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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.