Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
Dr. Anita Louise Jackson is an ENT specialist. Dr. Jackson runs several ear, nose, and throat clinics in the Raleigh, NC area. She helped several of her local health departments respond to the COVID-19 pandemic. She’s also named in a $46-million Medicare fraud scheme.
The indictment dives into each charge in detail. We’ve summarized the 20+ counts below.
The recycling of “single-use” balloon sinuplasty devices.
Illegal payment and remuneration by regularly failing to charge and collect patient coinsurance obligations.
Billing Medicare based upon fraudulent records.
Using fabricated medical records to smokescreen Medicare audits.
These are criminal charges.
Dr. Jackson ranked among the nation’s most successful ENT providers in terms of revenue generated from balloon sinuplasty procedures. Her success likely struck watchdogs as strange since she mostly practiced in a rural environment. The most successful ENT practices, based on cash generated from these procedures, are often located in metropolitan regions.
Prosecutors allege between 2014 – 2018 Jackson billed Medicare fraudulently for $46 million. $5.4 million translated into profit for Jackson and her practice. Among the alleged fraudulent charges, 1,200 correspond to balloon sinuplasty.
The indictment describes her alleged process as follows:
JACKSON routinely concealed from her Medicare patients the true amount that they were obligated to pay for the balloon sinuplasty services that JACKSON was billing to Medicare in their names. Characterizing these services as a “Sinus Spa,” JACKSON and her subordinates routinely led patients to believe they owed either nothing, or only a small copayment of up to $50.
In fact, patients were obligated to pay hundreds – in some instances thousands – of dollars for the services. To induce the receipt of these services, JACKSON deceived and failed to inform the patients of their obligations, failed to collect the patient copayments, and ultimately caused the patient obligations to be written off without making genuine efforts to collect.
By engaging in this practice, Jackson caused Medicare to pay all, or nearly all, of her balloon sinuplasty charges for her Medicare-only patients, when Medicare was, in fact, only obligated to pay 80 percent of such charges. JACKSON profited from this scheme because it enabled her to reap millions in balloon sinuplasty payments from Medicare which might not otherwise have been incurred had the true patient obligations been disclosed.
We’ve enclosed an image below, lifted from the indictment, demonstrating a few instances of the (allegedly) fraudulent charges.
Jackson then allegedly spoofed medical records to throw auditors off her trail – at least in the short term.
Where to begin?
The recycling of the single-use sinuplasty balloons is an obvious no-no. These devices, inserted into a patient’s sinus cavity, are immersed in phlegm, mucus, pus, blood, etc. To be clear – the devices used by Jackson were not cleared by the Food and Drug Administration for re-use/reprocessing. Sure, some devices can be used “off-label.” Recycling single-use devices – hard to make the case.
To quote the indictment once again…
JACKSON was fully informed that the devices were strictly single-use devices, and that the devices were not intended to be reprocessed or sterilized. Nevertheless, across the relevant time period, JACKSON purchased no more than 30 of these devices. She reused the devices as a routine business practice, sometimes inserting the same device into more than one patient on the same business day. JACKSON failed to inform her patients that she was reusing the devices, and instead, represented on “Pre-Op Instruction for Sinus Spa” forms that the devices were sterile.
As for the rest: Do we really need to explain in detail why producing fraudulent medical records is bad form?
Jackson also faces charges related to…
Adulteration of medical devices…
Three counts of making false statements specific to health care benefits…
Two counts of aggravated identity theft…
Three counts of mail fraud…
If convicted, Jackson could spend a lot of time behind bars and see a fine of $250,000 – likely more. Prior to (and during) these alleged events, Jackson operated several successful ENT clinics.
We’re curious as to how this all plays out in court. We’ll report updates as they emerge.
One note: Many of these patients lived in rural, lower socioeconomic areas. It’s possible they did not have the money to pay their coinsurance. Nonetheless, Medicare mandates that these patients still be billed in good-faith. If uncollectable, so be it. But the process can’t begin with promising the patient they will only owe $50. In other words, Medicare does not want to see doctors writing off patient obligations in advance of the procedure. Medicare considers this an illegal inducement which causes over-utilization. Medicare considers this constructive remuneration to patients likely to influence the patient’s decision to receive services.
What do you think? Let us know in the comments below…
Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
Jeffrey Segal, MD, JD
Chief Executive Officer and Founder
Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With decades of combined experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
The obvious first question is how she pleads to the facts. Of she stipulates that they’re all true, that’s one thing. If she pleads not guilty to them, it’s a very different story. Where is the case now? Did she stipulate that the alleged facts are actually factual?
If charges are proven true, she should spend jail time, pay the money back, and lose her license.
It sounds like the doctor did some horrible things but she was a mensch for not charging patients the entire copayment. Why waste everyone’s time corresponding over a bill that would never be paid in full? Why stress the patient out? It is much more civilized, respectful and dignified to ask them to pay an agreed upon price ahead of time.
As for Medicare declaring this illegal, that is not a decision for them to make. It is for a provider to determine their fees. If they want to forgo collecting the entirety for which they are entitled that is their decision. Not collecting a deductible from a patient with a financial hardship is something for which a physician should receive accolades and not condemnation. Shame on the Federal Government for prosecuting anyone for this. That is one of many reasons I am not a Medicare provider; I do not want to subject myself to arbitrary and capricious laws written by their entrenched bureaucrats and enforced by an FBI eager to “catch” a doctor.
But don’t get me wrong – I am not defending anything else about her behavior – this is just about the copay.
Regarding copayments, You are correct – it is up to the practitioner to set his or her fees. However, every contract you sign with an insurance company, including Medicare, obligates you to make a good faith effort to collect the deductible and copayments. And, we are told, if we are going to accept a lower payment as payment in full, we are to notify the company so that they can adjust their payment downward to accommodate this – and the patient will still have their copayment – it will just be lower. Based on what you’ve written, I assume you don’t participate with any insurance companies?
hopefully she will be convicted and do the time in jail. Salomen Melgen MD, the Palm Beach Florida retina doctor who defrauded medicare for some 40 million dollars and was convicted and was to do 20 yrs in jail unfortunately was able to get the last pardon from Trump and is a free man. What is interesting with Melgen’s pardon, he was a huge democratic donor and best friends with US senator Menendez from NJ. (BOTH CHARGED WITH ACCEPTING AND PROVIDING BRIBE MONEY AND BOTH FOUND NOT GUUILTY). Unfortunately, Melgen had enough likely offshore $$ to payoff some Trump cronies.. Read about that doctor and what happened. It will make you sick what he did and got away with. I was a retina fellow with him in the 80s at the Mass. Eye and Ear Infirmary
Out of curiosity, Dr. Baldinger, did you ever see any “irregularities” in Melgen’s practice or billing when you served under his fellowship? You were probably not in a position to see this, based upon your academic relationship with him. But you may or may not have had some perhaps unconscious suspicions? Was he “busy enough” to provide you with sufficient clinical practice?
It is difficult to imagine Donald Trump to be “bribed.” His cronies, certainly possible. During the Abraham Lincoln administration, there were large lines of people standing outside the WH to request various Government jobs and other advantages. Lincoln actually listened to them. It was exhausting, I’m sure.
My Dad always said: “Sometimes you have to wait your entire life for justice and despite that, it still never comes.” I’m sure that Dr. Melgen lost many nights sleep imagining himself in prison before the (unexpected) pardon. Despite Melgen’s posited enormous estate…whatever is left, I’m sure neither you nor myself would trade place with him.
Michael M. Rosenblatt, DPM
It is remarkable that “sophisticated” physicians who do large Medicare billing would be unaware of the contract they have that requires they bill for co-insurance. Medicare wants that billed because it tends to “reduce” the number of cases that a doctor will do, because patients do not want to pay their co-insurance.
I used a large number of implants in my DPM surgery at my Medicare Certified ASC. Sometimes I had to throw some away that I did not size properly at surgery. I “could” have re-sterilized them with Ethylene Oxide but never did, because they were already opened up. I’m sure I would never have been caught. But I still didn’t do it. It would not be right. There was incredible level of trust in me.
It seems unlikely to me that this doctor would not expect Medicare to stumble on what she was doing. For example, at the small suburban city I practiced in, Medicare knew almost exactly what a doctor in my specialty billing would be, well in advance. There are only so many hours/day.
Medicare also “expects” some complaints from patients about their co-insurance billings. If they don’t get any at all, given a certain volume of surgeries done, they KNOW you are not billing them. As part of my certified ASC, Government inspectors analyzed my charts periodically. They already had the billings. They knew exactly what I was doing.
I fail to understand why MDs would take those chances. Their “honest” income would certainly allow them to purchase rental Real Estate to build their retirements. If I did, they certainly could. Medicare would never audit my non-medical income portfolio. It’s hard to have sympathy for her.
Michael M. Rosenblatt, DPM