Deeper Than the Headlines: Patient Whistleblowers

Most of the time, whistleblowers are employees or someone internal to an organization. In the recent guilty verdict of Dr. Syed Ahmed, a surgeon in New York, it appears from court documents that patient complaints triggered the HHS-OIG and FBI investigations which led to the doctor’s trial.

The guilty verdict was announced on July 28, 2016. The billing scheme entailed using various surgical CPT codes for incision and drainage along with CPT modifier -78- which is supposed to indicate a particular surgical procedure was performed as part of an unplanned, return trip to the operating room.

Court records indicate that HHS-OIG special agents first interviewed the two Medicare beneficiaries who called Medicare to complain. Both complained about receiving a Medicare EOB (explanation of benefits) for procedures performed on them by Dr. Ahmed, that never occurred.

Patient #1 was a female Medicare beneficiary whose daughter called Medicare to complain that her mother had not received some of the services that had been reported by Dr. Ahmed. The daughter lives with the mother, has power of attorney for her mother, and takes care of her medical affairs. According to interviews, the story begins with patient #1 at home, having stomach pain. She went to the hospital emergency room where she was seen by Dr. Ahmed. The patient remained in the hospital for several days. During this time Dr. Ahmed did see the patient on multiple occasions during her stay. Eventually, it was determined that the patient needed surgery but she was transferred to another hospital to have the surgery performed by someone other than Dr. Ahmed. Though Dr. Ahmed examined the patient multiple times while in the hospital, the patient and her daughter said she never had any surgical procedures or incisions while at the first hospital. However, according to the EOB, Dr. Ahmed billed Medicare for an initial patient visit (CPT 99223) twice as well as various abscess drainage procedures (CPT codes 22015, 27301, 22015).

The pattern for patient #2 was very similar. She also called and complained to Medicare after she, too, received an EOB stating Dr. Ahmed performed procedures on her behalf which she knew had not taken place. Similar to patient #1, this second patient’s EOB stated that Dr. Ahmed had performed incision and/or drainage procedures over the course of multiple days while she was in the hospital. Reported CPT codes: 22015, 27031, 27603, 28001, and some of the codes were reported multiple times. Patient #2 stated in interviews with investigators that she was taken from her primary care doctor’s office to the emergency room of the same hospital where patient #1 had been seen. Patient #2 stayed in the hospital for many days while being treated for dehydration and colitis. She said she never saw Dr. Ahmed at any time and never had any surgical procedures performed on her during her hospital stay.

Court documents show that similar billings for incision and/or drainage procedures submitted by Dr. Ahmed for several other patients were also never performed. One of the more egregious examples included billing for over 480 procedures supposedly performed by Dr. Ahmed on one patient over a four-month period of time. Almost all of these procedure codes were submitted with the -78 modifier to presumably bypass surgical global package bundling edits.

It appears that the doctor performed one or two services on a given patient and then, to increase reimbursement, excessively billed for multiple procedures that never took place. He submitted the claims with modifier -78 to obtain the additional reimbursement.
On another patient, he even submitted bills for procedures he claimed to have performed on a date a week after the patient had died.

Prior to indictment, investigators interviewed Dr. Ahmed. Regarding some of the incision and drainage procedures, Dr. Ahmed stated that sometimes he made a slight incision to drain the wound properly and that these kinds of incisions were done bedside and are so minor that they might not be noticed by the patient.

In total for a two-year period covering January 2011 to mid-December 2013, the Medicare claims submitted by Dr. Ahmed totaled $85 million in billings of which Medicare paid him over $7 million in reimbursement. A claims review was performed on Medicare data for CPT code 22015 (incision and drainage of lower spine or sacrum). For the period of time reviewed, Dr. Ahmed was paid $2 million in reimbursement for claims with this code. The next highest provider in the country of this service for the same time period only received $13,600 in reimbursement.

After Dr. Ahmed was arrested and during trial he was held in custody. Bank records showed that he’d transferred millions of dollars to bank accounts in Pakistan shortly after his interviews with investigators. Obviously, there were concerns he might flee the country. Other reports claim the government has put a lien on his $4 million home. Additional court transcripts are still pending to be released to the public and they are bound to show even more interesting details and evidence of his scheme.

An important takeaway to this story for compliance programs is that it’s important to listen to internal employees who might complain of potential wrongdoing, it might also benefit compliance programs to elicit feedback of concerns from patients as well. When you think of it, they are ultimately paying the bills and more and more today such patients are scrutinizing all the services reported on their claims. In fact, almost all Medicare EOB’s include a hotline number patients can call if they suspect fraud. It appears it only took a couple of patient calls to get the investigation rolling in this case.