Reference no: EM133361670

Scenario:

Mary, a medical assistant, is employed by a large ophthalmology medical practice in Maryland. Mary's job description list technical and administrative duties. One of Mary's primary job duties is to submit claims for services rendered during the day and post payments. Mary is a single mom with two children, one who has an autoimmune illness and requires medicine which costs 300 dollars each month. She does not have health insurance and struggles to make ends meet.

While Mary and her friend Sue (a medical assistant who works for an optometrist in Maryland) have lunch one day, they discuss how they could bring more patients into the practice. Mary suggests that Sue's doctor send all of the patients who want refractive surgery to her practice and Mary's doctors can do the refractive surgery procedure and then Sue's doctor can do the 90 day follow up. Both understand that the doctor performing the procedure is paid for the procedure and all follow up visits for 90 days after performing the procedure.

For the next three years, Sue's practice sees the patient for follow up care for 120 days. Mary submits the claim for payment of the procedure without a modifier (without modifier means the doctor gets paid 100% of his contract rate which includes a visit prior to surgery; the surgery and follow up care for 90 days.

Mary and Sue continue their arrangement for about 3 years until Sue got a different job. At the beginning of the 4th year, Mary and her doctor are accused of violation of false claims (fraud).

Question:

1. Did Mary and Sue violate Maryland's scope of practice?

2. Which of them are guilty of a crime?

3. Would the crime(s) be prosecuted at the Federal or State level? Why?