Executive Brief Series: Insights on Recent OIG Enforcement Actions & Trends

Preventing Unlicensed Individuals and Subsequent Fraudulent Claims Submission

Written by A. Michael Rosen, Esq. and Donna Thiel

On June 7, 2022, Theresa Pickering of Norcross, Georgia was indicted by a federal grand jury on federal charges of health care fraud, aggravated identity theft, and distribution of controlled substances. The U.S. District Attorney alleges that Pickering was hired in 2019 as a licensed physician’s assistant at a family practice in Norcross, Georgia but had not been a licensed physician’s assistant in Georgia, or any state, since March 2014.

According to the U.S. Attorney’s Office press release, during her time at the practice, Pickering allegedly posed as a licensed physician’s assistant and issued prescriptions for controlled substances, “in the name of Doctor 1, a physician contracted by the practice, without Doctor 1’s permission.” Further, Ms. Pickering “treated patients, diagnosed illnesses, ordered diagnostic tests and lab work, handled sick visits, and prescribed drugs to patients, including prescriptions for controlled substances.” This resulted in the practice submitting at least $147,000 in fraudulent claims for reimbursement to Medicare and numerous private insurance companies.

In addition to these allegations of fraud, waste, and abuse, Pickering had a history of fraud. She was hired at the family practice in Norcross, Georgia after serving a prison sentence for 2015 state and federal fraud and narcotics convictions related to her illegal practice as a physician’s assistant in Mississippi. Both the act of posing as a licensed physician’s assistant and practicing without a license have placed patients in danger and put multiple health organizations at risk.

The Importance of Conducting License Verification and Monitoring

So, how could this situation have been avoided? In order for a person to perform certain services, state laws govern whether a state-issued license or certification is required. Therefore, it is necessary for the Employer to conduct an initial background check that confirms (among other things) whether an individual has a current license. But remember, a license can be revoked, suspended, not renewed, or even sanctioned after its initial issuance. Therefore, effective compliance practice includes not only an initial license verification but routine license monitoring to ensure a practitioner’s license remains in good standing.

Completing routine monitoring may be difficult if you are not using a third party for your license and exclusion monitoring needs, but there are a few manual ways that an Employer can conduct license verifications/monitoring in order to prevent fraud, waste, and abuse in their organization. One idea would be to start with quarterly verifications. Once you have the hang of checking each state licensing board you can increase it to monthly. Remember – every licensing board behaves a little differently. You will need to do some initial research to determine what information you need to complete the most efficient license verification. Always remember to download a copy of the license or capture a screenshot of the verification for future audit purposes.

When it comes to verifying licenses or when checking for name matches against the OIG exclusion list and various state boards, it is important to be vigilant for name mismatches, particularly in the case of last name changes. Unfortunately, a name mismatch is often overlooked and can actually be a sign that someone may have purposefully failed to update their name in hopes of preventing their employer from finding a previous licensure issue under that former name. You should also be aware of peculiar birth dates and/or a history of frequent relocation.

In the situation involving Theresa Pickering, she had not been a licensed provider since March 2014 and therefore should never have been able to be employed as a physician’s assistant when she was hired in 2019. It is possible that her relocation from Mississippi to Georgia allowed her to evade license checks. Stop-gap measures to detect misrepresentation can help you catch a bad actor before they are able to jeopardize patient safety.

Compact Licensure and License Monitoring

Some states allow a properly licensed individual to work in other states. The Nurse Compact Act (NPA) is a multi-state agreement that allows nurses to practice in any participating state, and can sometimes be tricky to monitor. It enables nurses to move across the country without obtaining any additional licenses, but the process is complicated (to say the least).

Recently, a new multi-state medical license compact has become available. The Interstate Medical Licensure Compact and NCSBN Nurse Licensure Compact have created more flexibility in interstate and electronic care delivery. While many state medical boards have eased restrictions on interstate licensed providers, these individuals must be licensed to practice in at least one state or territory within the United States. Additionally, during the recent public health emergencies, many states implemented changing licensure requirements which may have been continued even after the public health emergency was lifted. It is essential to keep an eye on the continuously changing licensure landscape.

Key considerations include:

  • Increased multi-state licensed providers
  • Less friction for obtaining a license in multiple states
  • Increased credentialing and privileging efficiency

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 an exclusion or a licensure issue. Additionally, the license verification services of ProviderTrust include screenshots of the artifact delivered directly from the primary source – including verifying name changes and identifying any potential license issues. By automating your license monitoring and using enriched data, you can be sure your organization isn’t spending federal healthcare dollars with unlicensed or excluded providers, and most importantly, is keeping your patients safe.

Learn more about a comprehensive and automated license and exclusion monitoring solution

Michael Rosen, Esq.

A. Michael Rosen, Esq.

Partner, Co-founder, ProviderTrust

Michael is an expert in designing and developing innovative tools in risk management and compliance industries that tackle real-world problems that make healthcare smarter and safer. He brings over 25 years of experience in founding and leading service-oriented businesses and is an active speaker and presenter at compliance, legal, and risk conferences.

Donna Thiel
Donna Thiel

Chief Compliance Officer, ProviderTrust

Donna brings over 30 years of experience in the long-term care industry to lead the vision, execution, and strategy of our compliance vertical and operation. She is an active speaker on compliance strategy and an industry thought leader.

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