James Carthron, M.D., 61, of Saginaw, Michigan, faces 23 Medicaid criminal charges alleging fraudulent Medicaid billing for virtual visits that reportedly did not occur. The Attorney General’s Health Care Fraud Division announced that each count could lead to financial penalties and up to four years in prison if he is convicted. The case focuses on billing between May 31 and September 27, 2024.
Like federal enforcement actions, Telehealth Medicaid fraud enforcement remains a national priority. Oversight of remote billing has grown nationwide, including in Georgia, where Medicaid and Medicare audits are underway. Allegations like these can expose providers to serious criminal and civil consequences.
Griffin Durham Tanner & Clarkson LLC’s healthcare fraud lawyers represent licensed professionals and healthcare organizations in government investigations and criminal fraud cases.
What fraud risks are emerging in Medicaid telehealth services?
Medicaid telehealth services let patients access care in more settings, but they also introduce challenges in documentation and verification. Investigators continue to find:
- Billing for appointments that never occurred
- Upcoding virtual visits as higher complexity services
- Orders for durable medical equipment without a documented need or delivery
- Templated documentation that cannot confirm accurate care
- Kickbacks
- Billing audio-only visits at video visit rates
- Claims submitted in states where the provider has no licensure or established relationship
Misused patient information can also lead to claims filed under stolen identities, sometimes creating large numbers of false bills that appear legitimate.
Why is telehealth fraud more difficult to detect?
Telehealth often involves fewer verification steps than in-office care. Enforcement challenges include variability in electronic health records used for virtual visits and delays in matching billed services to confirmed patient encounters.
Privacy rules also restrict recording virtual appointments unless a patient consents explicitly, adding an additional detection challenge. These conditions can create uncertainty about whether the provider and patient ever meaningfully interacted.
Who investigates Medicaid telehealth billing fraud in Georgia?
Government agencies at both the state and federal levels investigate Medicaid telehealth billing concerns. The agency involved depends on the scope of the allegations and whether claims were submitted to government payers in Georgia or across multiple states.
Common investigative authorities include:
- The U.S. Department of Justice (DOJ), which prosecutes federal healthcare fraud offenses
- The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), which evaluates improper Medicare and Medicaid claims
- The Federal Bureau of Investigation (FBI), especially in multi-state enforcement initiatives
- Georgia’s Medicaid Fraud Control Unit (MFCU), which reviews state-level provider fraud
- State licensing boards that evaluate professional misconduct concerns
Providers may first learn of scrutiny through a subpoena, a civil investigative demand (CID), an audit letter, or a notice from a contractor, like a Unified Program Integrity Contractor (UPIC). Some cases focus only on billing errors, while others involve criminal exposure tied to intent. Early legal guidance can help clarify the nature of the inquiry and how to respond without increasing risk.
Griffin Durham Tanner & Clarkson LLC has represented licensed professionals responding to federal investigations. The firm’s team includes former federal prosecutors who understand how agencies pursue criminal healthcare fraud allegations and how to address concerns before they escalate.
How can providers reduce the risk of fraud allegations?
Healthcare providers can take several steps to strengthen compliance when offering telehealth services:
- Verify patient identity and provider licensure before each visit
- Document the services delivered with accurate detail
- Match billing codes to actual visit duration and complexity
- Maintain records supporting medical necessity for testing and equipment
Routine internal audits help identify discrepancies early and may reduce the risk of investigative escalation.
Why are telehealth compliance efforts important for providers?
Telehealth continues to expand access to care, and oversight continues to expand along with it. Investigators are watching remote billing patterns closely, and even unintentional errors could lead to inquiries with costly consequences. Providers who maintain clear documentation for more accurate billing and seek strategic legal advice remain better positioned to protect their practices.
What should someone do if they suspect telehealth billing fraud?
People who notice billing concerns in a healthcare workplace or who believe claims were filed for services never received can explore options for reporting. Federal and state laws provide certain protections in qualifying situations.
Griffin Durham Tanner & Clarkson LLC helps individuals understand reporting implications before any contact is made with authorities. Contact us online, call our Atlanta office at (404) 891-9150, or get in touch with our Savannah office at (912) 867-9140.
