Medicare fraud is rampant. It is a disease found all over the United States. Dozens of people currently serving prison sentences for their roles in ripping off the taxpayer funded healthcare system.
Earlier this year the Justice Department, FBI and Health and Human Services special agents arrested 243 people in a massive nationwide sweep. Most of those headed to prison are the owners of clinics and home health agencies. It’s the owners and senior managers that frequently get sentenced to prison, not medical coders and billers. Unfortunately for Mary Talaga, a medical biller at a visiting physician practice in Illinois, she is the rare exception.
Last week a federal judge sentenced Talaga to 45 months in prison for her role in a $4 million Medicare fraud scam. When she is finally released from prison she must also pay $1 million in restitution.
Talaga, age 54, was convicted earlier this year after a jury trial of Medicare fraud, conspiracy to commit Medicare fraud and making false statements.
Because prosecutions against billers and coders are so rare, her story is worth telling.
Prosecutors claimed that Talaga was the primary biller at a medical practice that made home health care visits. According to the indictment and evidence at trial, Talaga was knowingly billing Medicare for services never provided.
Medicare Fraud – Upcoding – Billing for Services Not Performed
Garden variety Medicare fraud often involves what is called “up coding”, that is charging for a higher level of service than what was provided. More serious are frauds involving services that were never even performed. The Justice Department claims that Talaga was billing for patients who were dead, billing for physicians that no longer worked at the practice and in some instances billing so much time for some doctors that they would have had to work more than 24 hours in a day!
In other words, the violations were flagrant.
Another nail in Talaga’s coffin was her form of payment. Most medical billers get paid by the hour or on salary. Talaga’s pay, however, was based on how much Medicare paid. She had a financial incentive to cheat Medicare.
Talaga’s actions were so brazen that according to the government’s sentencing memorandum, Talaga continued to bill for dead patients even after Medicare alerted her to the fact that the patients had died!
Talaga didn’t act alone, although she was the only biller that was charges. It appears that another coder participated in the Medicare fraud scheme but prosecutors say she was threatened and coerced to break the law. She also left fairly quickly. (More on that later.)
As noted above, a jury also convicted Talaga of making false statements. Special agents say that when they questioned Talaga she claimed, “not to know anything” about the practice. When pressed, she then claimed the billing was done by “the Mexicans” and unpaid interns from a local college. Prosecutors also say she lied to a federal Grand Jury.
If the sentence sounds stiff, the practice’s owner, Rick Brown, was sentenced to 7 years in prison. The practice’s medical director was also convicted but not yet sentenced. Prosecutors had asked that Talaga receive a sentence of approximately 121 months (10 years).
We frequently speak with medical billers and coders. Some are scared given the sentence meted out to Talaga. Our advice to them and anyone who may be an unwilling participant in a Medicare fraud scheme is to speak with a lawyer as soon as possible and stop participating in the fraud.
There is sometimes a fine line between following orders and actively aiding a fraud scheme. While Talaga appears to be way over the line, we caution everyone that the longer you knowingly participate in a Medicare or Medicaid fraud scheme, the worse it looks for you.
Often we can turn a negative into a positive. Under the federal False Claims Act, Medicare fraud whistleblowers can receive a percentage of whatever the government collects from wrongdoers. The statute can prohibit active participants in the fraud from collecting an award but those just following orders usually get their reward. [We warn everyone that simply calling the Medicare fraud hotline does not earn you an award. You must have inside information about the fraud, be first to report and file a lawsuit in federal court.]
Last year the government paid $635 million to whistleblowers, many of them in Medicare fraud cases. These numbers don’t include the tens of millions of dollars paid by the states in Medicaid fraud cases.
Interested in learning more or concerned that you may have crossed the line? Give us a call. The consultation is free, confidential and covered by the attorney – client privilege.
MahanyLaw – America’s Medicare Fraud Lawyers