Conspiracy was uncovered in nationwide telemedicine fraud investigation

SAVANNAH, GA: A Georgia woman has admitted taking part in a nationwide telemedicine kickback scheme that led to fraudulent Medicare reimbursements for durable medical equipment and genetic testing.

Robin Darnell, known to some of her co-conspirators as “Nurse Robin,” 57, of Dallas, Ga., pled guilty in U.S. District Court to an Information charging her with one count of Conspiracy, said David H. Estes, Acting U.S. Attorney for the Southern District of Georgia. The plea agreement subjects Darnell to a possible statutory sentence of up to five years in prison and substantial financial penalties and restitution, followed by up to three years of supervised release.

There is no parole in the federal system.

“Telemedicine has played an increasingly important role in providing accessible healthcare, particularly during the pandemic,” said Acting U.S. Attorney Estes. “With our law enforcement partners, we will continue to work diligently to identify and shut down those who would attempt to use technology and deceit to defraud taxpayer funded safety net programs.”

As described in court documents and testimony, Darnell admitted that from June 2018 through September 2020, she and other conspirators took part in a nationwide telemedicine kickback scheme in which she recruited physicians and other medical professionals to sign orders for durable medical equipment and genetic testing. Darnell claimed to have a team of nurses who would contact patients to conduct exams via telemedicine on behalf of the physicians, in exchange for the health care professionals ordering medical equipment and expensive genetic testing for those patients. In fact, Darnell had no such team of nurses, despite claiming otherwise to the physicians she recruited. Darnell processed thousands of orders, which Darnell knew contained medical histories, conditions, diagnoses, or examinations that Darnell knew were false.

Darnell’s conspirators then used these orders to bill Medicare for thousands of dollars each. Medicare beneficiaries were located in the Southern District of Georgia and elsewhere.

“Telemedicine has become a valuable tool for delivering health services in this time of pandemic. However, bad actors are abusing these tools to commit health care fraud,” said Derrick L. Jackson, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services. “When marketing and so-called telehealth services are misused, alleged violators can expect aggressive investigation and swift prosecution.”

“Darnell took advantage of a system that was set up to help healthcare patients get much-needed government assistance during a pandemic,” said Chris Hacker, Special Agent in Charge of FBI Atlanta. “Her actions not only affect those patients, but every citizen whose tax dollars support programs like Medicare. The FBI is determined to hold her accountable and anyone who would commit such fraud.”

The Southern District of Georgia has now charged 33 defendants as part of the nationwide crackdown on fraudulent genetic testing, and prescribing of orthotic braces and pain creams, identifying more than $1.5 billion in losses to Medicare and Medicaid for defendants charged in the Southern District alone.

This investigation is ongoing. As telemedicine becomes an increasing part of our healthcare system, particularly during the COVID-19 pandemic, vigilance in ensuring that fraud and kickbacks do not usurp the legitimate practice of medicine by electronic means is more important than ever. If you are aware of any fraud or kickbacks relating to telemedicine, including COVID-19 fraud, please call the FBI hotline at 1-800-CALL-FBI.

The case was investigated by the FBI and the Health and Human Services Office of the Inspector General, and prosecuted for the United States by Assistant U.S. Attorney Jonathan A. Porter.

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The Biden administration's plan to cover the cost of home COVID-19 tests does not apply to Tricare beneficiaries.

Beginning Saturday, private and group health insurers will be required to reimburse the cost of eight take-home COVID tests per month under an initiative announced by President Joe Biden on Jan. 10.

But as a federal health program, Tricare's nearly 8 million beneficiaries who aren't on active duty will not have the same access, although the military health system is reviewing its policies, according to a Defense Health Agency spokesman.

Under Tricare, tests are covered only when ordered by a doctor for patients with symptoms; who have had prolonged exposure but no symptoms; are having surgery; or are overseas and need to be tested.

All other reasons -- personal concern, workplace safety, returning to work or school, travel or access to services -- are not covered.

In a major effort to broaden access to testing across the U.S., Biden ordered insurers to cover the cost of eight COVID-19 test kits per month for people with health insurance starting Jan. 15.

The initiative requires insurers to reimburse for the full cost of take-home tests at their network pharmacies and at out-of-network retailers for a $12 copayment per test.

And under the directive, patients with an underlying health condition or other factors will not be limited on the number of tests they can be reimbursed for if they have a doctor's order.

Since the beginning of the COVID-19 pandemic, Tricare beneficiaries have been able to have their COVID-19 tests covered only if they have symptoms or have been in contact with a person who has tested positive and they have a doctor's order.

Tricare spokesman Peter Graves said Thursday that policy remains in place but the Department of Defense is reexamining its rules.

"The Defense Health Agency is reviewing the latest guidance on at-home testing kits in order to identify whether any changes to the current policy are warranted," Graves said in an email to Military.com.

The new insurance reimbursement plan also does not apply to Medicare, which provides the primary coverage for military beneficiaries who use Tricare For Life – meaning those patients are also excluded under the initiative.

Despite not being covered under the federal program's reimbursement plan, Tricare users should still be able to get access to free tests.

As part of the announcement, the government will establish "thousands of locations," according to Biden, to distribute free take-home tests and will create a website for anyone to order free rapid antigen tests for delivery.

Beginning Jan. 19, anyone can order free tests for home delivery at www.COVIDTests.gov.

Some states like Vermont already have programs in place that require insurers to reimburse for tests. Other states, including Colorado, Connecticut, Iowa, Maryland, Massachusetts, New Hampshire, New Jersey and Washington, as well as the District of Columbia, already have been giving away free tests at COVID-19 test sites, community centers, libraries and community health clinics.

With the spread of the Omicron variant of the illness, test kits have remained in short supply at retailers and via community distribution.

Earlier this month, the Defense Department awarded contracts to a number of rapid antigen test makers, including Abbott, maker of the BinaxNOW test; iHealth Lab; and Roche Diagnostics for the purchase of 380 million over-the-counter tests, and to Goldbelt Security for distribution of a planned 500 million tests.

The DoD is the contracting agency because it has the infrastructure and capability to "acquire goods and services as rapidly and effectively as possible for the federal government in support of the American public," according to Pentagon spokeswoman Jessica Maxwell.

There have been more than 460,000 cases of COVID-19 diagnosed in the military community since the beginning of the pandemic, including military personnel, family members, civilian employees and contractors.

Nearly 650 have died, including 88 troops, 34 dependents, 394 civilians and 133 contractors, according to the DoD.

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Medical practice billed Medicare for expensive urine drug testing it did not use

BOSTON – Nevada Advanced Pain Specialists (NAPS), a Reno-based medical practice, has agreed to resolve allegations that it submitted false claims for payment to Medicare for medically unnecessary urine drug testing (UDT).

Pursuant to the settlement agreement, NAPS admits that it ordered confirmatory UDT—testing designed to confirm the results of presumptive UDT—despite failing to first obtain presumptive UDT results. In fact, NAPS did not consult the presumptive UDT results before ordering their confirmation but continued to perform presumptive tests in-house and bill Medicare as if they were medically necessary. NAPS admits that its performance of presumptive UDT played no role in its medical decision-making regarding whether to order confirmatory UDT from a clinical laboratory.

“NAPS ordered presumptive testing in order to collect more from Medicare, not because the tests were medically necessary,” said Acting U.S. Attorney Nathaniel R. Mendell. “It’s not supposed to work that way, of course. NAPS was improperly draining resources from an important federal program, and we commend it for resolving the matter expeditiously.”

“Healthcare providers are expected to closely follow Medicare rules and bill properly — nothing more, nothing less,” said Special Agent in Charge Phillip M. Coyne of the U.S. Department of Health and Human Services, Office of Inspector General. “When that obligation is violated, government health care programs – and American taxpayers – pay the price. We are committed to pursuing these types of allegations along with our law enforcement partners as we work to protect the integrity of our federal healthcare system.”

“Public health insurance programs, such as Medicare, incur staggering financial losses when their programs are exploited. Today’s settlement should make it perfectly clear that those who bill for medically unnecessary tests will be held accountable,” said Joseph R. Bonavolonta, Special Agent in Charge of the Federal Bureau of Investigation, Boston Division.

This settlement resolves claims brought as part of a lawsuit filed by a whistleblower under the qui tam provisions of the False Claims Act, which allows private parties to bring suit on behalf of the government and to share in any recovery. In connection with today’s announced settlement, the relator will receive $150,000 of the recovery.

Acting U.S. Attorney Mendell, HHS-OIG SAC Coyne, and FBI Boston SAC Bonavolonta made the announcement today. The Department of Veterans Affairs also provided assistance. Assistant U.S. Attorneys Abraham R. George and Charles B. Weinograd of Mendell’s Affirmative Civil Enforcement Unit handled the matter.

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