An Overview of Recent Enforcement Actions Against Nurse Practitioners and Physician Assistants

Advanced practice practitioners (APPs), such as physician assistants and nurse practitioners, are not exempt from the different types of compliance enforcement actions we have seen for many years taken against physicians. It does not appear such enforcement will slow down any time soon – let’s look at some examples.

Injections Made by Physician’s Assistant

In July 2023, a Texas physician assistant (PA) who allegedly injected amniotic fluid into patients’ joints in an attempt at pain management has been charged with healthcare fraud.

Certain amniotic products have been approved by the U.S. Food and Drug Administration for wound care, but not for pain management. Because amniotic products have not been approved to treat pain, Medicare considers amniotic injections administered to treat pain medically unnecessary and does not reimburse them. They do reimburse for some – but not all – amniotic injections administered to reduce inflammation of damaged tissue, as in a wound.

This PA allegedly told patients that the treatment was covered by Medicare. According to the indictment, he and others allegedly submitted $788,000 in fraudulent claims and received more than $614,000 in reimbursements from Medicare for injecting amniotic fluid. According to the press release, he allegedly billed using a code (Q4206) that, under appropriate circumstances, can be reimbursed by Medicare for covered purposes, but the PA allegedly used it to bill for non-covered services.

Nurse Practitioner and Opioid Prescribing

A nurse practitioner (NP) was sentenced to 30 years imprisonment in June 2023 for illegally prescribing and dispensing opioids outside the scope of legitimate medical practice. She was also ordered to forfeit $117,000 in unlawful proceeds.

Enforcement involving inappropriate prescribing and dispensing of opioids has been a major area of compliance scrutiny for many years now.

Evidence presented during the trial showed the NP prescribed and dispensed 4.5 million dosages of opioids in just over five years, including fentanyl, methadone, oxycodone, and hydromorphone. Many times, she combined those prescriptions with prescriptions for dangerous drugs like valium and muscle relaxers, known as the “holy trinity,” greatly increasing the chances of overdose death.

In imposing the sentence, the judge emphasized the trust that society places in medical practitioners and remarked that “when [practitioners] fail in their responsibilities, [they] can do far greater harm than the drug dealer on the street corner.”

Physician Assistant and Medically Unnecessary Services

In June 2023, a federal jury returned a guilty verdict against a PA for his role in a genetic testing scheme that resulted in the submission of more than $10 million in fraudulent claims to Medicare.

According to trial evidence, witness testimony, and documents filed with the court, the PA worked as an independent contractor for a physician staffing and telemedicine company. During the relevant time frame, the PA signed fraudulent prescriptions for medically unnecessary genetic testing (specifically cancer genomic and pharmacogenetic testing) for hundreds of Medicare beneficiaries. The PA had never met, seen, or treated the beneficiaries, and only had brief telephone conversations with them or no interactions at all.

Trial evidence also showed he received from the telemedicine company and its clients pre-populated prescription forms and related records for patients who were pre-selected for genetic testing, which he then electronically signed and returned, in exchange for $12—and later $15—for each purported consultation that he performed.

Nurse Practitioner and Medically Unnecessary Services

Earlier in 2023, three Tennessee medical providers agreed to settle allegations of False Claims Acts violations relating to the submission of claims seeking reimbursement for autonomic nervous system testing.

The United States and Tennessee contended that the Internal Medicine group violated the False Claims Act and the Tennessee Medicaid False Claims Act (FCA) by submitting claims for non-reimbursable and/or medically unnecessary autonomic nervous system testing during the period of January 2, 2015, through April 28, 2021. As a result of the settlement, the practice will pay $440,518.84, of which $264,050.17 is restitution.

In addition to the practice, an NP will pay $315,000 in restitution under the terms of the settlement. Her payment will settle allegations that she violated the FCA by submitting claims for non-reimbursable and/or medically unnecessary autonomic nervous system testing.

Conclusion

These are just some of the many enforcement actions focused on APPs, and the types of enforcement are essentially the same kind of actions that physicians have been exposed to for years. These include billing issues, opioid prescriptions, anti-kickback, and medical necessity errors. If your compliance program oversees professional providers such as physicians and APPs, you can be assured both groups of providers are exposed to compliance risk.

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