Attorney and former DOJ prosecutor Gejaa Gobena has tried numerous people throughout his career, serving as head of the Department of Justice's healthcare fraud unit from April 2013 to June 2016. Mr. Gobena told Medscape Medical News that Medicare is particularly vulnerable to fraud due to its many beneficiaries. He noted, "It's really difficult to police a public health insurance system which has as many beneficiaries as it does while also trying to maintain its goal of paying physicians and other providers as quickly as possible."
Mr. Gobena details what characterizes a fraudulent physician and factors driving providers to commit crimes.
Here are six things to know:
1. The primary factor Mr. Gobena believes that drives providers to commit fraud is financial difficulties coupled with age. If a physician is nearing the end of his/her career, fraudulent schemes may serve as a 'quick fix' to make a fair amount of money. Such financial difficulties may include personal bankruptcy or a divorce leading to alimony and child support.
2. Throughout his career, Mr. Gobena did not prosecute many specialists. Rather, many internists would bill for tests and services that did not add up. He told Medscape, "You'd see a primary care physician suddenly billing for an unusually high percentage of, let's say, nerve conduction tests. Very expensive, and usually done by neurologists."
3. Some physicians work for a clinic owned by non-physicians. Owners may sometimes get physicians in predicaments that cross legal territory. Mr. Gobena explains, while it is hard for physicians to get out of these situations, many do volunteer to be part of the scheme initially.
4. As a prosecutor, he would often try patient recruiters, who criminal practices hire to offer patients some incentive to visit an office and receive services. Many physicians would sign off on tests that were not medically necessary. Mr. Gobena told Medscape, "The doctors would sign off even though it didn't make sense to have that high of a percentage coming to a general practice having these exact same symptoms. They often would prescribe opioids in addition."
Many patient recruiters already have a criminal background and look for Medicare and Medicaid patients to go to clinics for services.
5. When physicians go to trial, the core of their defense is whether they rendered the service and whether it was medically necessary. If a patient did not receive services, the physicians would often say that because they prescribed the services, they expected them to be rendered and they should not be held responsible if a home health aide or nurse did not perform the prescribed services.
In terms of medical necessity, physicians would argue it was their medical opinion and they cannot be prosecuted if someone has a different medical opinion. If convicted, many physicians try to minimize their role, saying "I made a mistake and it was an awful mistake," Mr. Gobena told Medscape. Many physicians claim although they acted knowingly, they had no intention of breaking the law.
6. Mr. Gobena said he believes most physicians are good people doing "wonderful work" and only a small minority partakes in fraudulent schemes. However, those who do commit these crimes need to remember their role as providers. He said, "It's important for all practitioners to keep in mind what their practices are. It's about doctors taking that gatekeeping role very seriously, helping preserve the integrity of the system.
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