The Healthcare industry is a heavily regulated and complex business. It is rare now for doctors to receive the full payment for their services directly from their patients. Rather, a complex system involving insurance companies, HMOs, and federal and state agencies are all part of the payment process.

On Wednesday, an Atlanta doctor was sentenced to one year and three months in federal prison for Medicare and Medicaid fraud. The 77-year old Atlanta doctor was also sentenced to an additional three years supervised release. He will be required to pay restitution of more than $700,000 to Medicare and $200,000 to Georgia Medicaid. He pled guilty this summer to six charges of federal health care fraud.

According to law enforcement officials, beginning in 2007, the doctor contracted with a health care organization to provide psychological services to nursing home patients. Over the course of two years, there were about 55,000 Medicare claims filed under the doctor’s provider number. This resulted in payments to the doctor of about $750,000.

There were also about 40,000 Medicaid claims filed using his number during the same time period. The doctor was paid about $225,000 for these reported services.

But law enforcement officials contended that he did not provide all the services for which he was billing. An investigation by the FBI and Georgia’s Medicaid Fraud Control unit allegedly showed that many of the doctor’s reported patients were actually deceased or were not in a nursing home setting. Prosecutors argued that it would have not been possible for the doctor to have actually provided all of the services for which he submitted claims.

Source: Atlanta Journal Constitution “Atlanta doctor gets prison for Medicare, Medicaid fraud,” David Ibata, Oct. 12, 2011