Radiologist slapped with $2 million fine for billing fraud blames recordkeeping

March 26, 2009

A radiologist implicated in one of the largest billing fraud cases in Medicare history is blaming poor recordkeeping for a federal investigation and prosecution that led him and his partner to a $2 million settlement with Department of Health and Human Services Office of Inspector General. Settlement terms were announced March 25.

A radiologist implicated in one of the largest billing fraud cases in Medicare history is blaming poor recordkeeping for a federal investigation and prosecution that led him and his partner to a $2 million settlement with Department of Health and Human Services Office of Inspector General. Settlement terms were announced March 25.

To settle Medicare's false claims allegations, Dr. William L. Boren and Dr. Luke S. Cesaretti agreed to the multimillion-dollar fine and entered into a five-year integrity agreement requiring periodic inspections of West Valley Imaging, a radiology service they jointly own and operate in Las Vegas.

OIG alleged that the two board-certified radiologists defrauded Medicare by billing it for imaging procedures that were not supported by physician orders and failing to satisfy other billing and coverage requirements. Boren and Cesaretti contested the allegations and deny liability.

Rather, the real culprit was bad recordkeeping by West Valley and its referring physicians, Boren said in an interview with Diagnostic Imaging. OIG found during an onsite audit in 2004 that physician orders were missing from many patient files. Even worse, orders for imaging services charged to Medicare were frequently not found when OIG inspected the files of referring physicians who asked for the procedures.

"Clearly for us, recordkeeping is what got us killed," Boren said. "At the time, we didn't have an electronic system. That made it clearly impossible for us to do the things we wanted to do."

Boren said he did not know what sparked the original inspections, but OIG alarms may have been triggered by his practice of allowing other radiologists who read at West Valley to charge Medicare with his billing number.

"It looked as though I was doing this astronomical amount of business," he said.

Boren said that he and his partner thought they had successfully negotiated a $900,000 agreement with the U.S. Justice Department after charges were filed in 2005, but that arrangement fell apart about six months later when OIG intervened. It demanded a $2 million fine and threatened to pull Boren and Cesaretti's Medicare billing privileges. Those rights were retained as part of the settlement.

"This could happen to anybody. They're going to find stuff in an inspection like this, no matter who you are. Referring docs have got to feel that vulnerability, just like everybody," he said.

West Valley Imaging consists of two separate full-service facilities equipped with digital mammography, ultrasound, two 64-slice CT scanners, 1.5T and 3T MRI, and PET. Boren, Cesaretti, and a radiologist employee read for the services.

An OIG representative was not immediately available for comment.

For more information from the Diagnostic Imaging and SearchMedica archives:

Federal legal opinion opens door to referring physician kickbacksStates get new False Claims Act authorityBeware of precertifying procedures for referrers