In a rare victory, a physician turned the tables on the government and won nearly $300,000 in legal fees for what a Nevada federal trial judge found to be a frivolous health care fraud case.
The Justice Dept. accused otolaryngologist Mark Capener, MD, now in Idaho Falls, Idaho, of billing for endoscopic sinus surgeries that investigators alleged either were unnecessary or never performed, and of upcoding. Authorities accused the doctor of defrauding eight private health insurers, Medicare and Medicaid through his billing practices.
Instead, in many cases, "[the government] is just looking at CPT code usage and anybody out on the tail of the distribution is targeted for criminal prosecution," Parker said. "And that's not the same thing as intentional wrongdoing." If found guilty, doctors could face 10 years in prison, noted Parker, who assisted in Dr. Capener's suit.
Tate said that although Dr. Capener may have done more surgeries than what might be considered "normal" among other doctors, he did what was best for his patients.
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