At the end of an all-day sentencing hearing in U.S. District Court on Thursday, Judge J. Randal Hall told Dr. Jeffrey Sponseller that what troubled him most about the hours of testimony was the defense’s apparent theme that bad employees and sloppy record-keeping were to blame.
“When it comes to health care fraud, a lot of people look at these types of cases and say, ‘Well, it’s just the government,’ ” Hall said. But it’s a crime against all taxpayers who must pay for care of the elderly and disabled covered by Medicare, Hall said.
Sponseller, 48, pleaded guilty in February to filing false claims. On Thursday, he admitted he defrauded Medicare and other government health care programs from January 2008 through 2010.
The investigation centered on Sponseller’s billing for Eye Care One services for nursing home patients in Georgia.
Because of the amount of fraud – which was the subject of Thursday’s hearing – Sponseller faced a sentencing range of 33 to 37 months in prison.
Defense attorney Pete Theodocion challenged the government’s calculations that Sponseller defrauded Medicare of more than $441,000.
The Medicare billing code Sponseller used most often was for the most comprehensive exam possible that would be needed for a new and medically complex case, according to testimony from Jean Stone, the director of the Northeast Integrity Field Operations of the Centers for Medicare and Medicaid Services.
When Stone studied case files collected from Sponseller’s office and nursing homes, the documentation was completely inadequate for such billing. In fact, it was so minimal that it wouldn’t qualify for any kind of Medicare payment, she said.
Kim Reinken, an investigator with the U.S. attorney’s office, analyzed Sponseller’s billings and case files, finding that on a single day in July 2009, he billed Medicare for the 45-minute comprehensive exam on 177 patients.
She also found that Sponseller was the highest recipient of Medicare payments for that billing procedure in the nation. The second-highest recipient billed for less than half of what Sponseller did.
FBI Special Agent Paul Kubala testified that at one nursing home, Sponseller billed for comprehensive exams of 59 patients in about three hours. Four of those patients told the nursing home director that they never saw Sponseller, and another patient didn’t have eyes.
An investigator with the Office of Inspector General of Health and Human Services, David Graupner, testified that in 2007, Sponseller was audited and placed in specialized tutoring for Medicare billing because of questionable billing practices.
In 2009 and 2010, one of the billing codes Sponseller used was for a specialized photograph. No such photographs were found in any of his patient records, Graupner testified.
Assistant U.S. Attorney David Stewart argued that the nearly half-million dollars in restitution was a reasonable request. The government wasn’t seeking repayment of more than $1 million paid to Sponseller over the two-year period in question.
In the end, the judge sided with the prosecution. A telling factor for Hall was that while Sponseller was billing for a procedure required for a difficult diagnosis or a very ill patient, rarely did he seek payment for follow-up treatment of these patients.