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N.Y Surgeon Sentenced in Multi-Million-Dollar Health Care Fraud.

In: Business and Management

Submitted By anastacija89
Words 1249
Pages 5
Abstract.
Heath care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Health care schemes come in many different forms like: billing by practitioners for care that they never rendered, filing duplicate claims for the same service rendered, altering the dates, description of services, or identities of members or providers, modifying medical records, intentional incorrect reporting of diagnoses or procedures to maximize payment, prescribing additional or unnecessary treatment. In this paper, I will examine the Multi-Million-Dollar Health Care fraud that was committed by one surgeon, who worked in NY hospital. I will also apply the fraud triangle and go over detection and prevention steps.

Introduction.
Spyros Panos was a board certified orthopedic surgeon licensed to practice medicine in the State of New York. Between 2006 to 2011, Panos performed a huge amount of orthopedic procedures that helped him to make lots of money from his fraud schemes. He had back-to-back surgeries and had 12-hour surgery days. Most of the time Panos had two patients under anesthesia at the same time. He performed short operations and some of them were seven minutes long. (Nina Schutzman, 2014).
The records showed the times of surgeries and administering of anesthesia but did not contain a description of the procedures or names of patients. Panos high volume of surgeries a day raised a red flag and his patients filed lawsuits accusing him in botching surgeries, doing unnecessary surgeries on healthy patients, or faking surgeries and prolonging patients’ ailments.
He talked to his patients only for 3-5 minutes before the surgery and never seen them after. Two of his patients filed a lawsuit because they had a knee surgery performed by Panos and did not get any improvement after. They were claiming that the doctor did not even perform any required procedures during the surgery because it lasted only for 7-10 min.
Analysis and Prevention.
A false billing scheme is always carried out in service account categories like professional fees. Because it is harder to prove a service was not performed as opposed to trying to conceal a good that was never purchased or received. The service being falsely billed would be either nonexistent or unnecessary. In this case, Panos was not performing services but was billing customers. It was hard to prove that service was not performed due to the nature of business. One of his patients with the knee surgery however, proved it by the X-ray, which showed that nothing was done to it. (Sarah Bradshaw, 2013)
Fraud triangle helps to explain the nature of many occupational offenders. In most fraudulent acts, there are three circumstances lead to the commission of fraud: pressure, opportunity, rationalization. Pressure is the first step in the fraud triangle. This case did not give any description of his needs or intends of stealing so much money that is why I assumed that the pressure was his lifestyle. His patients filed almost 260 lawsuits against him and it did not make him stop his fraudulent activity. Probably he had to pay for his high-end lifestyle (nice car, house etc.).
Regardless of strength of pressure, fraud will definitely take place if the opportunity is presented. Opportunity is the only step where company has control. If company will reduce the opportunity by straightening internal controls, the possibility of the fraud to occur is decreasing. He wasn’t watched by anybody while his surgeries so he could write anything on the report. Certain types of segregation of duties should be presented in surgery practices. Usually the person assisting the doctor make notes and help the doctor with maintaining records. However, doctor Panos was keeping records himself and they just showed the times of surgeries and administering of anesthesia but did not contain a description of the procedures or names of the patients. Therefore, after surgeries Panos could easily make up some procedures as being performed.
The last step in the triangle is rationalization. One type of rationalization is when people do not care about consequences. I think this one would fit this case. I know that doctors make a lot of money and this case did not specify doctor’s problems or addictions. Knowing this I assumed that he was too greedy and could not stop stealing.
The biggest part in the prevention of this scheme falls on patients, and the rest of it on the Hospital internal controls.
- The segregation of duties should be in place. By proper hospital internal controls, the same person cannot handle patients and billing them.
- Internal audit should be performed yearly.
-Every patient after care should review the statement to verify the accuracy. In Health Care industry, it is hard to understand the terminology health care specialists are using in billing statement. That is how Panos took advantage of his schemes.
-Ask your doctor to explain the reason for services. The doctor was too busy with his other surgeries (he had average of 17 a day) that the only time he saw his patients was before the surgery for 3-5 min. After the surgery was made, patients saw only his assistants. The luck of time helped him to commit the crime, because he did not have to explain anything to patients.
- Patients should report any discrepancies to your health insurance plan or payer.
The red flag for Panos fraud schemes was his high volume of surgeries. During four days, he performed 69 surgeries, or an average of 17 per day. (Sarah Bradshaw, 2013). His highest volume day was 19 surgeries in ten and a half hour. His volume of surgeries ranged from ten in six and a half hour to twenty in twelve hours. He had three cases where he had surgeries of two people being scheduled at the same time and performed at the same time. The main detection step was when his patients did not see any improvement after surgeries and filed lawsuits.
Conclusion.
In this paper, I analyzed a white-collar scheme. After going through application of fraud triangle, detection and prevention steps, I realized that this type of fraud is very hard to detect due to its nature of business. Patients do not understand their billing statements because doctors use special terminology. I think the prevention and detection in this case depends on patients. They should talk to their doctor about services performed, and try to understand the application of services in the bill. Hospitals should follow stricter internal controls and have internal auditors yearly. Panos 12 hour surgical days are not the normal practice and if hospital used the proper controls this scheme could have been prevented.

Bibliography.
Sarah Bradshaw (2013 January 6). Records: Spyros Panos averaged 17 surgeries per day. Retrieved from http://archive.poughkeepsiejournal.com/article/20130721/NEWS01/307210064/Records-Spyros-Panos-averaged-17-surgeries-per-day
Nina Schutzman (2014, October 28). Judge to issue decision Wed. on Panos lawsuits' delay. Retrieved from http://www.poughkeepsiejournal.com/story/news/local/2014/10/27/medical-group-seeks-stay/18034897/
Dutchess County Orthopedic Surgeon Sentenced. In White Plains Federal Court To 54 Months For Multimillion Dollar Health Care Fraud scheme. (2014 March 7) Retrieved from http://www.justice.gov/usao/nys/pressreleases/March14/panosspyrossentencing.php
Liz Neporent. (2014 March 7). Retrived from http://abcnews.go.com/Health/judgment-day-surgeon-admitted-fake-surgeries/story?id=22814868
Understanding Health Care Fraud. Retrieved from http://www.bcbs.com/report-healthcare-fraud/…...

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