Last week, the Department of Justice (DOJ) announced charges against a former hospital CFO, two orthopedic surgeons, a chiropractor, and a health care marketer for their alleged roles in a series of fraudulent referral and billing schemes. According to the DOJ, these referral schemes paid illegal kickbacks to physicians for spinal surgery referrals and caused “nearly $600 million in fraudulent billings over an eight-year period.” These charges underscore the federal government’s recent emphasis on greater individual accountability for fraudulent healthcare schemes and the potential for those involved to face significant liability.
According to a statement from the U.S. Attorney’s Office, the schemes generally involved paying tens of millions of dollars in kickbacks for referrals to two California hospitals, Pacific Hospital in Long Beach and Tri-City Regional Medical Center in Hawaiian Gardens, for spinal surgeries. Those hospitals then billed those surgeries to California’s workers’ compensation system, the U.S. Department of Labor, and workers’ compensation insurers. The schemes implicated dozens of surgeons, orthopedic specialists, chiropractors, marketers, and other medical professionals.
These charges are the latest development in an ongoing coordinated government investigation dubbed “Operation Spinal Cap.” The investigation is specifically focused on providers and other individuals who may have been involved in these spinal surgery-related schemes.
In early 2014, the ex-CEO of Pacific Hospital was indicted and pleaded guilty to paying illegal kickbacks and federal conspiracy charges. He was also the subject of a qui tam suit and a suit by the County of Los Angeles on state false claims grounds. According to those cases, the CEO used a network of shell corporations, physician-owned distributorships, and sham contracts to facilitate the referral and billing schemes.
Notably, not all improper kickback payments are clear-cut cash transactions. The schemes described above are alleged to have used multiple vehicles for providing and concealing kickback payments. For example, the U.S. Attorney’s Office statement described several “bogus contracts” deployed as part of the Pacific Hospital referral scheme. These included agreements where physicians were paid for a “right to purchase” their medical practices, but the option was never exercised; operations-based agreements that compensated physicians at rates above fair market value; agreements for consulting or directorship work that was never performed; and even lease agreements that paid doctors for space that was never or rarely used. Corporations should be mindful of these improper arrangements when structuring their compliance programs and evaluating their financial relationships with physicians.
Pacific Hospital’s former CFO, whose case was unsealed last Tuesday, was allegedly responsible for, among other things, tracking the referrals from and payments to physicians. He pleaded guilty to participating in a conspiracy that engaged in paying kickbacks in connection with a federal healthcare program and in mail fraud, among other charges. The charges brought against the individuals are varied. For example, one orthopedic surgeon was charged with filing a false tax return; his plea agreement admits he did not report his kickback payments as income on his taxes. Additionally, a health care marketer who admitted to recruiting doctors to make referrals pled [...]