In October 2014, the following case was heard in New Jersey. A former optometrist was sentenced to seven years in state prison for conspiracy, theft by deception, falsifying records, and falsification of records relating to medical care, as part of a massive health insurance fraud. In addition to his prison sentence, the optometrist was ordered to pay a criminal insurance fraud fine of $100,000 and restitution of 597,975. The state is also in the process of seeking an additional $810,000 in civil insurance fraud penalties.
The optometrist was found guilty of false insurance billing for providing eyeglasses and routine eye exams at no cost or at reduced cost and making up the difference by billing insurance carriers for services not rendered to patients. The optometrist also had his office staff create approximately 997 false patient records and charts and falsely bill insurance carriers for prescribed optometric services that were not rendered to his patients. He would also bill insurance companies for optometric treatments and tests for ocular conditions that patients did not actually suffer. The optometrist was also charged with falsifying patient records and charts. What factors provided the optometrist with an opportunity to commit fraud?