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Physician acquitted of $15M Medicare Fraud Conviction

A federal court overturned a Maryland physician’s conviction for his involvement in a $15 million Medicare fraud conspiracy, according to a post by the legal firm Husch Blackwell on JD Supra.

According to a Justice Department news release dated August 4, Ron Elfenbein, MD, was originally found guilty on five counts of healthcare fraud for submitting over $15 million in fraudulent and misleading claims to Medicare and other insurers for COVID-19 testing at locations run by the physician.

According to Husch Blackwell, the Justice Department concluded that Dr. Elfenbein’s billing of level 4 assessment and management claims for patients undergoing COVID-19 testing constituted inappropriate use of the billing codes, which served as the basis for his sentence.

On December 21, Dr. Elfenbein’s request for acquittal was approved by the same federal judge who presided over his first trial. Based on the pertinent guidelines, the judge determined that Dr. Elfenbein’s use of the more expensive level 4 codes did apply to the patient encounters because E/M CPT codes, the kind of medical billing codes he used, are imprecise and intended to give; according to Husch Blackwell.

"physicians flexibility to exercise their best judgment given the multitude of factors that go into medical decision-making"


The court determined that “imprecision does not necessarily integrate well with the clear notice and due process guarantees of our criminal law” as well as “where the relevant CPT codes and related definitions are ambiguous and subject to multiple interpretations, problems clearly arise,” according to the court files.

The legal company concludes that the healthcare industry should protect itself from government action that is based on unclear or inaccurate healthcare principles.

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