The conviction of a Maryland physician for his role in a $15 million Medicare fraud scheme was vacated by a federal judge, according to a post by law firm Husch Blackwell on JD Supra.
Ron Elfenbein, MD, was originally convicted of five counts of healthcare fraud for submitting more than $15 million in false and fraudulent claims to Medicare and other insurers for COVID-19 tests at sites operated by Dr. Elfenbein, according to an Aug. 4 news release from the Justice Department.
The conviction of Dr. Elfenbein was based upon his billing of level 4 evaluation and management claims for patients receiving COVID-19 tests, which the Justice Department determined was improper use of the billing codes, according to Husch Blackwell.
Dr. Elfenbein's motion for acquittal was granted Dec. 21 by the same federal judge who oversaw his initial trial. The judge found that because E/M CPT codes, the type of medical billing codes used by Dr. Elfenbein, are imprecise and designed to allow "physicians flexibility to exercise their best judgment given the multitude of factors that go into medical decision-making," his use of the higher-cost level 4 codes did apply to the patient encounters based on the relevant guidelines, according to Husch Blackwell.
The judge ruled that "imprecision does not necessarily integrate well with the clear notice and due process guarantees of our criminal law" and "where the relevant CPT codes and related definitions are ambiguous and subject to multiple interpretations, problems clearly arise," according to case documents.
The law firm concludes that the healthcare community should safeguard itself against government action based on imprecise or ambiguous healthcare concepts.