Ongoing License Monitoring Critical to Prevent Healthcare Fraud

A 49-year-old Brownsville, TX man, named Fernando Mendez was taken into custody in early September after being charged with defrauding Medicaid. Mendez, a physician assistant at CCI Therapy Counseling Centers International, was working with a suspended medical license.

On July 20th, 2021, the Texas Medical Board allegedly ordered an immediate suspension of his license after an investigation revealed that Mendez had violated ethical boundaries by initiating a sexual relationship with a patient. Deemed a “continuing threat to public welfare,” Mendez was prohibited by the Board from practicing medicine.

However, despite his suspended medical license, Mendez continued to treat patients at various mental health clinics in Brownsville, Harlingen, and Pharr, TX. From August 2021 to February 2022, Mendez provided patient assessments and evaluations and ordered treatments and prescriptions, all while billing Medicaid for his services. During this time, Mendez also allegedly created false medical records and assumed the identity of another physician traveling outside of the US.

Mendez faces seven counts of healthcare fraud and up to 10 years in federal prison. Mendez could face an additional two years in prison if convicted of identity theft, which must be served consecutively to another imposed prison term. These numerous counts of fraud also carry a possible fine of up to $250,000.

This prosecution points to the urgent need for healthcare organizations to stay up-to-date on changes in license status, not just verifying them when they are about to expire. This means routinely verifying practitioner credentials. If you are only verifying a license upon hire, annually, or as expiration approaches, you could miss important eligibility changes, in many cases, risking patient safety and healthcare fraud.

In Fernando Mendez’s case, the clinics where Mendez practiced with a suspended license could have become aware of his fraudulent activity much sooner had the organization more routinely verified the practitioner’s license. Organizations should conduct background checks on all employees to confirm their licenses are valid and up-to-date as part of their pre-hire process. As we know, licenses can be revoked, suspended, or not renewed, so it’s important to conduct routine license verification checks as opposed to only completing an initial license verification.

How Often Should You Verify Employee Licenses?

Consistently verifying licenses may be difficult if you do not use a third party to assist with license and other types of practitioner monitoring, such as federal and state exclusion monitoring, CMS Preclusion List, Medicare Opt-out, etc., but consider starting with quarterly verifications. Each licensing board operates differently, and you will need to do some initial research to determine what information is needed to verify licenses efficiently. Once your organization understands the ins and outs of checking each state licensing board, you can increase your verifications to monthly. Organizations should download a copy of licenses or take screenshots of verifications for future audit purposes.

In order to ensure a comprehensive process to verify your practitioners may work within your organization and ensure compliance across state and federal regulations, healthcare organizations should monitor important exclusion lists, including:

  • The LEIE issued by the US Department of Health’s OIG
  • The GSA-SAM exclusion list
  • State Medicaid Exclusion (Sanction/Debarment) lists

Reimagine your healthcare license monitoring

An automated license and exclusion monitoring solution like ProviderTrust is an even more comprehensive way to monitor your providers and protect your organization against compliance risk. Automated license verification and exclusion monitoring will screen employees, providers, and vendors against the applicable licensing board and every state and federal exclusion source up to daily, so you’ll never miss a licensure issue or exclusion.

By automating your license monitoring and leveraging our always-accurate compliance intelligence, you can be sure your organization isn’t spending federal healthcare dollars with unlicensed or excluded providers and in turn, creates a safer healthcare for all patients.

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