Reference no: EM133288229 , Length: word count:400
Case Study - Healthcare Quality
Overview
In order to complete this case study, refer to this week's readings for policy information required to analyze and make recommendations on this case.
As a healthcare quality fraud analyst, you are responsible for identification of root causes and providing recommendations in an action plan to ensure compliance with federal and state quality policies.
Instructions
Read the Department of Justice story, "South Jersey Doctor Charged in Health Care Fraud Billing Scheme." Then, write a 1-2 page report in which you:
Summarize three quality issues in the case that resulted in fraudulent billing and coding.
Describe three violations that were stated in the case, including how the violations applied based on regulations.
Illustrate how this case could be used as a training tool for your organization. You may base your work on the Department of Health and Human Services Office of Inspector General (DHHS-OIG), the Center for Medicare and Medicaid Services (CMS), and the Department of Justice (DOJ) information on quality, fraudulent billing, and so on.
South Jersey Doctor Charged In Health Care Fraud Billing Scheme
CAMDEN, N.J. - A South Jersey doctor was charged in connection with his role in a longstanding billing fraud scheme, U.S. Attorney Craig Carpenito announced today.
Morris Antebi, 68, of Long Branch, New Jersey, is charged by complaint with three counts of health care fraud, wire fraud, and mail fraud for his role in the scheme. Antebi is scheduled to appear today by videoconference before U.S. Magistrate Judge Joel Schneider.
According to documents filed in this case and statements made in court:
Antebi, a physician specializing in pain management and anesthesia, owned and operated a pain management clinic chain with locations throughout South Jersey. Antebi was a participating provider in Medicare, Medicaid, and several private insurance plans. Between approximately 2014 through 2020, Antebi billed over $24.6 million for services he purportedly provided, including billing more than $15.3 million to Medicaid and more than $8 million to Medicare.
The investigation showed that Antebi engaged in various forms of billing fraud. For example, Antebi frequently billed Medicare, Medicaid, and private insurance companies on dates when travel records show he was overseas, including on trips to China, Israel, Turkey, the Dominican Republic, and across Europe, or when he was otherwise outside the State of New Jersey. Antebi billed approximately $230,700 to Medicaid, Medicare, and private insurance plans between November 2015 and January 2020 for services he purportedly rendered while he was traveling and not in the office.
The investigation also showed that Antebi billed for excessive billings for one-day periods of time. For example, Antebi billed insurance plans for more than 24 hours' worth of services in a one-day period of time on more than 900 occasions between 2014 and 2020. Antebi also billed insurance companies for between 12 and 23.99 hours of purported services in a one-day period of time on more than 300 occasions. On certain occasions, law enforcement surveilled Antebi on days when he left the clinics early, but nevertheless billed as though he saw many patients on those days.
Despite these high billings, individuals interviewed during the investigation stated that Antebi commonly saw them for only very brief periods of time, and he often did not perform any medical exams or evaluations during their visits. Individuals also indicated that that there sometimes was no medical equipment or examination tables in the rooms at the clinics in which patients met with providers, and that patients sometimes met with providers on folding chairs in the hallway of the clinics.
The health care fraud count carries a maximum penalty of 10 years in prison and a $250,000 fine, or twice the gross gain or loss from the offense. The wire fraud and mail fraud counts each carry a maximum penalty of 20 years in prison and a $250,000 fine, or twice the gross gain or loss from the offense.
U.S. Attorney Carpenito credited agents of the FBI's Atlantic City Resident Agency Health Care Fraud Task Force, under the direction of Special Agent in Charge George M. Crouch Jr. in Newark; the U.S. Department of Health and Human Services - Office of Inspector General, under the direction of Special Agent in Charge Scott J. Lampert, the U.S. Department of Labor - Office of Inspector General, New York Region, under the direction of Special Agent in Charge Michael C. Mikulka, the U.S. Drug Enforcement Administration, under the direction of Special Agent in Charge Susan A. Gibson in Newark, and IRS-Criminal Investigation, under the direction of Special Agent in Charge Michael Montanez in Newark with the investigation leading to the criminal complaint. U.S. Attorney Carpenito also thanked agents of FBI's Headquarters Health Care Fraud Unit Data Analysis Response Team under the direction of Special Agent Greg Heeb in Washington, D.C. and officers of the Northfield Police Department for their assistance with the case.
The government is represented by Assistant U.S. Attorneys Christina O. Hud and Daniel A. Friedman of the U.S. Attorney's Office in Camden.
The charges and allegations contained in the complaint are merely accusations, and the defendant is presumed innocent unless and until proven guilty.
Defense counsel: TBD