Health Law Daily Wrap Up, ADMINISTRATION OF MEDICARE/MEDICAID PROGRAMS—DAB DECISIONS: Surgical tech’s five-year exclusion for falsifying patient records justified, (Aug 27, 2025)

By WK Editorial Staff

The surgical technician was involved with falsifying patient records for unnecessary cataract surgeries.

The HHS Departmental Appeals Board (DAB) Provider Reimbursement Review Board (PRRB) determined that a five-year exclusion of a surgical technician from participating in Medicare and Medicaid was permissible because the tech’s criminal conviction was related to delivery of services under these programs. The tech was involved in a scheme orchestrated by a manager, who falsified patient medical records at an ophthalmology practice in Prescott Valley, Arizona. For over nine years, she and her colleagues manipulated results from visual acuity tests. The scheme was alleged to have enabled the physician-employer to justify unnecessary cataract surgeries, leading to improper billing to insurers, including Medicare and Medicaid. The practice received more than $25,000 based on these fraudulent claims (Heidi June Elmer, DAB No. CR6504, Doc. No. C-24-346 (July 11, 2024)).

The Inspector General’s (IG) decision to exclude the technician was based on her conviction on two felony counts: facilitation of fraudulent schemes and securing the proceeds of an offense. The conviction was part of a larger indictment involving 47 defendants charged with various felonies related to the criminal enterprise. Regulations mandate exclusion for individuals convicted of offenses associated with the delivery of items or services under federal or state healthcare programs.

In her appeal, the technician argued that she should not be excluded because she did not perform the actual billing. However, the IG's rationale emphasized that the statutory language of “related to” encompassed all individuals involved in program-related crimes, not just those who submit bills. The DAB noted that the interpretation aligned with previous rulings, providing examples involving a physician who certified patients for unnecessary services. The IG noted that falsifying treatment records represented a more serious violation than merely posting a bill, thereby justifying the surgical technician’s exclusion.

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