Health Care Fraud—Georgia

Eric and Christopher Topel—who practiced as chiropractors in “metro Atlanta, Columbus and Albany”—have pleaded guilty in a scheme that defrauded Blue Cross and Blue Shield “out of almost $2 million.”^[1]

While Christopher Topel pleaded guilty to one count of committing health care fraud on February 2, his brother, Eric, pleaded guilty today to two counts of committing health care fraud.^[2] The scheme involved a non-surgical back pain procedure known as Vertebral Axial Decompression [hereinafter VAX-D].^[3]

VAX-D is an investigational procedure, according to Blue Cross, and therefore not medically necessary, which means that it will not cover the procedure.^[4] The Topels, however, “sought and received reimbursement from Blue Cross for this non-covered procedure anyway, by misleading Blue Cross into believing they were instead performing other services.”^[5] They did this by using “an inapplicable medical billing code on their insurance claims that is only for surgical nerve decompression procedures” and by instructing “their employees not to call the procedure ‘VAX-D’ when speaking to Blue Cross representatives, and to conceal references to ‘VAX-D’ in the patient files.”^[6]

While the Health Care Fraud Unit of the FBI’s Federal Crimes Section categorizes health care fraud into at least nine different practices, it is important to realize that the statute is broad enough to encompass a wide range of activities. For example, many health care fraud cases involve billing insurers for services not rendered, or for “upcoding,” which is billing for a higher reimbursable service than performed. But unlike those scenarios, the VAX-D scheme here seemed only to involve billing for a procedure not covered. In other words, treatment was performed but not covered by Blue Cross. Therefore, it is a scheme that is not conveniently pigeon-holed. In a way, health care fraud is like mortgage fraud; it is not the type of activity that leads to an investigation, but rather whether the activity fits within the language of a statute.

The health care fraud statute states that it is a crime for a person knowingly and willfully execute a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, any money under the control of a health care benefit program, in connection with the payment for health care services.^[7]

Thus, the indictment in a health care fraud case need only allege how the scheme operated, contain language found in the health care fraud statute, and specify of what precisely the defendant was trying to defraud the program.^[8]

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[1] Chiropractors Admit Cheating BC/BS, Atlanta Bus. Chron. (via 11alive.com), Feb. 20, 2006.
[2] Id.
[3] Id.
[4] Id.
[5] Id.
[6] Id.
[7] 18 U.S.C. § 1347.
[8] United States v. Bobo, 344 F.3d 1076, 1084 (11th Cir. 2003). (PDF)