New Whistleblower Award Opportunities for Information about Teaching Physicians Engaged in Healthcare Fraud
Can you imagine being 82 years old, a highly respected physician at university teaching hospital and facing a decade in prison? That is the predicament Dr. Kenneth Rall finds himself in today after pleading guilty felony Medicare fraud. At the center of the controversy are allegations that Dr. Rall billed for diagnostic images they had never reviewed. Every year we see allegations of teaching physicians billing for work performed by residents.
CMS Guidelines for Teaching Physicians
The government understands that physicians at teaching hospitals perform a valuable service both to patients and to improving healthcare. Guidelines from the Centers for Medicare and Medicaid (“CMS”) allow so called teaching physicians to bill for their services if they actively supervised a resident performing the work.
CMS publishes a guidebook for both teaching physicians and the students (residents). Called “Guidelines for Teaching Physicians, Interns and Residents,” the rules are quite clear. They say:
“Billing Requirements for Teaching Physicians You must be identified as the teaching physician who involves residents in the care of your patients on claims. Claims must comply with requirements in the General Documentation Guidelines and E/M Documentation Guidelines sections. Claims must include the GC modifier, “This service has been performed in part by a resident under the direction of a teaching physician,” for each service, unless the service is furnished under the primary care exception. When the GC modifier is included on a claim, you or another appropriate billing provider are certifying that you complied with these requirements.
“If you meet the requirements in the Exception for E/M Services Furnished in Certain Primary Care Centers section, you must provide an attestation to the Medicare Administrative Contractor (MAC) stating that you have met these requirements. Claims must include the GE modifier, “This service has been performed by a resident without the presence of a teaching physician under the primary care exception,” for each service furnished under the primary care center exception.”
While CMS is notorious for “exceptions to exceptions to exceptions”, the rules generally say that as a teaching physician, you shouldn’t supervise more than 4 students at a time and must either be physically present or supervise from “such proximity as to constitute immediate availability.”
The rules also say that if the resident has less than 6 months experience, you must be physically present.
The teaching physician must also review the care or services performed during or immediately after the service and document the both the supervision and review.
Kenneth Rall Charged with Medicare Fraud
Rall was charged with Medicare Fraud along with another colleague, Dr. Michael Richards in July of 2017. From October 2008 until December 2011, Dr. Rall was chair of the Radiology Department at the University of Missouri’s School of Medicine. Dr. Richards was the university’s head of mammography.
Both doctors were rounded up as part of a nationwide Medicare fraud sweep by the Department of Justice in July of 2017. 412 people were arrested as part of that sweep including 115 physicians.
In announcing the nationwide arrests, newly appointed Attorney General Jeff Sessions said,
“Too many trusted medical professionals like doctors, nurses, and pharmacists have chosen to violate their oaths and put greed ahead of their patients. Amazingly, some have made their practices into multimillion dollar criminal enterprises. They seem oblivious to the disastrous consequences of their greed. Their actions not only enrich themselves often at the expense of taxpayers but also feed addictions and cause addictions to start. The consequences are real: emergency rooms, jail cells, futures lost, and graveyards.
“The criminal complaint properly notes that as teaching physicians, the two doctors can only bill for services performed by student residents if those services were “actually performed in the presence of the teaching physician and/or reviewed and evaluated by a teaching physician.”
Prosecutors say that the men charged for reviews of diagnostic images even though they were not present and did not review them. As charged by the government, the charges suggest that more than money is at issue. By not reviewing the work of students, we wonder if any of the new residents made diagnostic errors.
We also wonder how the University of Missouri even allowed this to happen. Dr. Rall was previously convicted of embezzlement while working at the university. Despite that, he was later promoted to the head of the Radiology Department. And that is not all, the radiology publication Rad Rounds reports Rall was also previously charged with felony Medicare fraud but those charges were dropped after a prosecutor lost key evidence.
At the time of his dismissal, Rall was earning $571,200 per year. This doesn’t include his private billings. Why the 82 year old was so desperate for money that he resorted to stealing is a mystery. He will be sentenced shortly.
Teaching Physician Whistleblowers Call to Action
MahanyLaw is the leading boutique whistleblower firm in the U.S. Our focus is on helping healthcare professionals put an end to fraud, corruption and greed. We prosecute these cases on behalf of whistleblowers and the United States. In addition to helping stop the fraud, we work to protect whistleblowers from illegal retaliation and to obtain the highest awards authorized by law.
Rewards? The Civil War era False Claims Act pays cash awards to healthcare professionals with inside information about fraud involving Medicare, Medicaid, Tricare and Indian Health Service healthcare. Awards are based on a percentage of the amount collected from wrongdoers. Million dollar awards are not uncommon.
In addition to the federal False Claims Act, approximately 29 states and the District of Columbia have their own award programs that pay even more when someone reports fraud involving state funded Medicaid.
Illinois and California even have laws that pay awards for information related to fraud involving private health insurance such as Blue Cross or Aetna.
For more information and to see if you qualify, visit our Medicare fraud information page. We also have special pages for specific type fraud schemes such as billing fraud schemes, Anti Kickback/ Stark law violations and homecare fraud.
You can also contact the author of this post, attorney Brian Mahany either online or by phone at (414) 704-6731. All inquiries are protected by the attorney – client privilege, even if you don’t hire us.