July 6, 2023
A doctor and resident of Anne Arundel County in Maryland was recently indicted for health care fraud in the approximate amount of $1.5 million or more.
According to the indictment, Ron Elfenbein, MD is the physician owner and medical director of a chain of urgent care centers in Maryland. The indictment alleges that he was part of “a scheme to defraud a health care benefit program,” and that his office offered COVID-19 testing during the pandemic, but had the testing bundled with more lucrative services that were unnecessary. It adds that the "additional" services were documented as lasting for 30 minutes or more when they only lasted for a few minutes. If convicted of all the charges, Elfenbein could face10 years in prison plus hefty fines.
The prosecutors are adamant, District Attorney Keith Clouser stating, “We have strict standards, and we don’t charge or issue indictments unless we are confident in the case.” Attorney, Mike Lawlor, who is representing Elfenbein responded, “in the early days of the pandemic, Dr. Ron Elfenbein rallied his doctor’s office in a time of global fear, to be a leading provider of COVID-19 testing and treatment in the community. These efforts enabled essential personnel, including police officers, firefighters, and health care providers to continue to perform their vital work. A trial in this case will prove not only that Dr. Elfenbein is innocent of the charges brought by the government, but that during a time of unprecedented need, Dr. Elfenbein and his staff saved the lives of numerous Marylanders."
In the case against Ron Elfenbein, a medical expert is extremely important. The government is alleging that Elfenbein billed for unnecessary services or that the services billed were not actually delivered. This has to be analyzed carefully. A statistically random sample of medical records from Elfenbein's practice is needed. Since the medical charts represent what was done and what was billed, the first task is to determine if the charts were coded properly. Does the documentation in the medical records reflect the actual codes assigned to each chart? Code levels determine the amount that should be billed to insurance or to a benefit program. Each code, therefore, has specific criteria that must be documented in order to substantiate the code assigned. A medical expert, that enlists in-house coders, must review Elfenbien's charts to determine if the codes are supported by the documentation. The second part of the allegations requires interviews with the providers who worked during the relevant period. These providers must substantiate that what they wrote in the charts was what actually happened, and that the work they did was medically necessary. Only a medical expert could make sense of results provided by coders and also understand precisely if the work performed was appropriate.
By looking at the charts and speaking to the providers, any errors in coding or in the clinical services delivered will be compiled into an expert report. That report will be important and useful for Elfenbein's attorneys so they can properly develop their legal defense strategy. Of course there are a number of outcomes: an expert will either substantiate the charges against this doctor or exonerate him. Regardless, the work of an expert will arm the defense with the cold hard truth about the risks involved and whether the charges actually have merit.