The common thread appears to be physicians willing to take money as administrators.
As we recently reported, according to Assistant Attorney General Brian A. Benczkowski of the U.S. Justice Department’s Criminal Division, “Philip Esformes orchestrated one of the largest healthcare fraud schemes in U.S. history, defrauding Medicare and Medicaid to the tune of over a billion dollars.”
Sadly, even if the amount of fraud in the Esformes case pans out as being accurate, it would barely make the top five fraud cases in the last 10 years. The fines levied against pharmaceutical giants like GlaxoSmithKline and its stunning $3 billion settlement in 2012 dwarf Mr. Benczkowski’s estimate. It is also very unlikely that regulators will recover more than pennies on the dollar on any of the fines that are finally assessed in the Esformes case.
One of the common threads in these cases is the fact that physicians were willing to take money in exchange for doing something other than caring for patients. Physicians were paid to prescribe drugs or refer patients to certain facilities in return for cash or other remuneration. Some of the physicians in kickback schemes like this are eventually charged. Many of them are not.
What is the answer to reducing kickbacks and fraud among doctors? First, you have to realize how easy it is to hide and rationalize kickback payments. The pharmaceutical industry often hires physicians to come to “speaking engagements” and pays large “speaking fees,” offering travel to exotic destinations. The physician thinks that this payment for services will appear normal to the outside world, even if someone does find out. “Anyway,” they think, “I am a brilliant physician, and I am really being paid what I am worth for speaking.”
In the case of Mr. Esformes, he was convicted in part for paying physicians as “administrators” in return for referring patients to his facilities. We can see physicians thinking that it is a common practice to pay them to provide administrative services to nursing homes, so who can prove that the payments were made in return for steering patients to the facility paying them?
In the 1950s, criminologist Donald R. Cressey came up with a hypothesis to explain why people commit fraud. The three key elements in the fraud triangle are an opportunity, perceived pressure, and rationalization.
In terms of the perceived pressure to make money, even for physicians and businesspeople like Mr. Esformes, who seem to have as much money as they could ever need, they seem compelled to commit fraud. I am reminded by a line from the movie Wall Street: Money Never Sleeps, the sequel to the landmark 1987 Oliver Stone film starring Michael Douglas as scheming insider trader Gordon Gekko.
Shia LaBeouf’s character asks James Brolin in the film, “everybody has an exact number – what is yours?”
James Brolin smiles smugly and replies, “more.”
It is a bummer when you get hoisted on the petard of intellectual inconsistency. Whether it is different medical professionals with different approaches to a
Picture this: You are driving through an area you don’t know well. It is a cold day. You stop to get gas. You fill the
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
