Two nurse practitioners who worked with Medicare patients in Montana admitted that they conspired to cheat Medicare of millions of dollars through exploiting Medicare’s telemedicine provisions.

Telemedicine is a substitute for an in-person visit with a medical professional and has become more prevalent because of the precautions taken by the medical community during the pandemic.  Medicare now funds telemedicine. Telemedicine allows for communication between a medical provider and a patient through the use of electronic equipment such as a computer or phone.  In other words, the patient and medical provider can speak by audio and video instead of an in-person visit.  The goal of the Medicare program is to allow continued visits between patients and their health care providers through live interactions even though the patient and practitioners are not at the same location. Medicare requires telemedicine visits to be conducted by audio, and in most cases, by video to allow the provider to conduct a face-to-face visit of patients. The Medicare program intends for telemedicine to be a cost-effective alternative to the traditional way of providing medical care through face-to-face consultations or examinations between a provider and a patient.  State Medicaid programs can also choose to cover telemedicine under the Medicaid program. State Medicaid programs can also choose to cover telemedicine under the Medicaid program. The Office of Inspector General for the United States Department of Health and Human Services, the agency that polices the administration of the Medicare program, is on the lookout for an uptick in telehealth fraud.

Two licensed nurse practitioners pled guilty to conspiracy to commit health care fraud.   They and numerous other healthcare providers nationwide were caught in a large-scale health care fraud and opioid initiative undertaken by prosecutors at the United States Department of Justice.   Earlier, on Sept. 30, 2020, prosecutors announced that they had charged over 340 health care providers, including over 100 doctors, nurses, and other licensed medical staff, with submitting more than $6 billion in false and fraudulent claims to Medicare and Medicaid programs and private insurance companies.  Over $4.5 billion of that money related to fraudulent activity involving telemedicine.

The two nurses who admitted their guilt were involved in a fraudulent scheme involving braces used in orthotics.    Orthotics is a medical specialty that focuses on the design and application of an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system.  A brace is a device used to support or treat muscles, joints, or skeletal parts which are weak, ineffective, deformed, or injured.  To prescribe, manufacture and manage orthotic devices requires in-person visits by patients to licensed medical practitioners.

However, for years the nurses traded their medical licenses in exchange for payments from staffing and telemedicine companies and signed orders for braces obtained by unlicensed telemarketers who had no training.  Patients received braces without ever having been seen by a health care provider.

Publicly available documents filed in court showed that these nurses ordered orthotics braces for Medicare patients’ events when the braces were not medically necessary.   The sheer number of braces ordered by these nurses and charged to the Medicare program was astonishing and led to the massive fraud on this important health care program for older Americans.  Combined they used their authority to sign orders for approximately 14,770 braces for which the Medicare program paid over $9,362,000 million dollars.

Healthcare fraud, such as the telemedicine fraud exposed in this case, is frequently brought to light through whistleblowers.  Whistleblowers are often employees who become aware of fraud being committed by their employer or by other employees.  Such people bring their knowledge to the attention of a government or law enforcement agency.  Whistleblower lawsuits are usually brought under the qui tam provisions of the False Claims Act, which allow private parties, known as “relators,” to bring suit on behalf of the government and to share in any recovery.  Whistleblowers are protected against retaliation under the whistleblower provisions of the False Claims Act.  For demonstrating a commitment to protect the integrity of Medicare and Medicaid, whistleblowers usually receive 15% to 25% of the government’s recovery.

The Department of Justice needs whistleblowers to report healthcare fraud to help protect healthcare programs and patients, and to hold accountable any company that commits fraud, waste, or abuse in the Medicare, Medicaid, and other government programs.