In December 2017, a fellowship-trained neuroradiologist in good standing was pulled off his teleradiology shift mid-interpretation by the police, put in handcuffs, and taken to jail. He was accused of reading ultrasound studies too quickly, approximately three to five minutes per interpretation, inconceivable to the district attorney and their hired plaintiff radiologist expert. Because there were Medicaid patients involved, he was said to be defrauding the government. The allegation was not due to misreads or any adverse patient outcome and in fact the radiologist had a clean bill of medical practice. The ordeal took a great toll emotionally and financially on the radiologist’s family, including his wife and children, and caused damage to his professional reputation with significant lost income due to unemployment and legal fees over seven years and counting. The radiologist was ultimately encouraged by his attorney to take a plea deal and he agreed to lose the battle but win the war. However, to date the radiologist credentials to practice medicine unhampered are still not fully reinstated. I currently serve as his practice monitor, auditing his interpretations for 36 months, a requirement for reinstatement. This radiologist has graciously agreed to share his story with our radiologist community with appropriate redactions, and it is my hope that our colleagues may learn from his experiences, be reminded to navigate the complexities of the health care landscape with heightened awareness and caution, maintain a delicate balance between trust and vigilance, and be inspired by this radiologist’s perseverance and dedication to recover his radiology career in the face of overwhelming adversity.

I am a dedicated radiologist who has pursued a passion for diagnostic radiology and neuroradiology. My journey in this field began with my fellowship training in Neuroradiology, which I completed in 2006. Since then, I have embarked on a fulfilling career as an attending physician, proudly holding privileges at esteemed institutions. One of the most rewarding chapters of my career unfolded when I served as a faculty neuroradiologist and had the privilege of leading the neuroradiology section for a decade, earning a respected reputation within the medical community. Beyond interpreting countless radiology images, I have found immense satisfaction mentoring and educating the next generation of medical professionals. Over the years, I have had the privilege of supervising and teaching radiology and internal medicine residents, helping to shape their knowledge and skills. My commitment to advancing the field of radiology has also led me to a role as a faculty when I proudly served as an assistant professor of clinical imaging. I have contributed to multiple publications throughout my career, sharing insights and knowledge with the wider medical community. In 2011, I started a part-time teleradiology job as a contracted independent provider for radiology practices. This decision was driven by my desire to support my family and ensure my kids received a quality education. In this role, my primary responsibility was to remotely interpret ultrasound scans, all facilitated through a secure system known as PACS (Teleradiology). I collaborated with various radiology practices, one of which specialized in neurology. One important thing to mention is that I did not handle the billing process directly. Instead, the radiology practices were responsible for managing the billing aspect, adhering to the regulations laid out by the State, Medicare, and Medicaid. My compensation was based solely on the number of studies I interpreted, and it was independent of the payments received by the practices from different insurance providers.

Here is a more detailed breakdown of the workflow: A patient would visit a primary care physician (PCP), who would then order the necessary diagnostic tests based on their medical judgment. Following this, the PCP’s office or the radiology practice would initiate the authorization process with the patient’s insurance company. Once the insurer granted approval, an ultrasound technician would perform the scans and send the resulting images to me via the secure electronic PACS system. It was my responsibility then to meticulously interpret these scans and create comprehensive reports, which I would then upload onto a secure platform. This platform allowed referring physicians and radiology practices to easily access and review my professional interpretations. At the close of each month, I would bill the radiology practices for my services, and my fee was calculated based on the number of studies I had read during that period. It is important to emphasize that I did not have control over which cases were assigned to me or the volume of cases received; these factors were determined by the radiology practices, leaving me to focus on delivering high-quality radiological interpretations. As an independent contractor, my role has always revolved around working in partnership with radiology practices, serving as a remote teleradiologist. I have consistently adhered to the prevailing industry standards by providing the necessary credential information for these practices. This typically includes sharing my National Provider Identifier (NPI), my license number, and my insurance provider number. The radiology practices then utilize this information for billing purposes, ensuring full compliance with the regulations set forth by the State, Medicaid, and Medicare. Throughout my tenure in this role, I have remained steadfast in following the rules and regulations stipulated by Medicare, and Medicaid. I have also diligently adhered to the established norms and standards of care for remote teleradiologists. My commitment to patient care has been unwavering, and I have consistently delivered expert professional readings without any compromise. Additionally, I have maintained open and regular communication with the radiology practices to ensure the highest quality imaging services are provided by ultrasound technicians. Beyond the realm of interpreting scans, I have also played a proactive role by advising primary care physicians (PCPs) on potential follow-up actions or the need for additional imaging modalities based on my interpretations. This collaborative approach has allowed me to contribute to the comprehensive health care needs of patients. Above all, my dedication to practicing medicine with passion and integrity has been my guiding principle. I am proud to share that I have a clean track record, with no adverse malpractice claims against me. My commitment to serving the community with excellence remains unwavering.

To my surprise, in December 2017, a startling situation unfolded. Among the various remote teleradiology practices I was engaged with, a group of radiologists, including myself, who worked for the same company were accused of participating in a fraudulent scheme allegedly orchestrated by the practice itself. It is crucial to emphasize that as teleradiologists, we had minimal interaction with one another and very limited contact with the practice itself, primarily through email. This limited interaction created an environment where the activities of the practice could go unnoticed by us and other doctors. What was particularly surprising was the revelation during the subsequent legal proceedings that the Practice had been under investigation since 2015. The discovery process shed light on a troubling scheme whereby the practice was engaged in fraudulent activities. Specifically, they were recruiting patients, and obtaining false insurance authorizations for these patients using our professional credentials, even though primary care physicians had ordered the tests. Subsequently, the practice was alleged to have fraudulently and illegally billed insurance companies, including Medicaid, using the radiologists’ credentials. It is important to underscore that the responsibility for determining the medical necessity of a test rests with the ordering physician, such as the primary care physician, not the radiologist or teleradiologist. This revelation came as a shock to all of us involved, as we had no knowledge of or involvement in the practice’s actions. The limited communication and information flow had effectively kept us in the dark about these illicit activities.

During the period in question, the practice tasked me with interpreting a mix of backlogged cases and more typical, recent ones, a common occurrence in busy medical settings. What sparked the interest of the district attorney (referred to as “the DA”) was the backlog, particularly cases dating back to March 2017. At that time, the practice provided me with explanations for the backlog, citing issues with new computer software installation and delayed uploads by sonographers. They also emphasized the urgency, claiming that patients were eagerly awaiting their results and were at risk. Little did I know, this urgency may not have been entirely accurate. Unbeknownst to me, the practice was recruiting and compensating individuals for unnecessary testing. Furthermore, it appears that when insurance companies requested medical records, including reports, the practice could not furnish them, as reports had not been generated promptly after the tests. In response, the practice misled us about the urgency of these reports to meet the insurance company’s demands for medical records. The DA also raised a concern as to the number of images I was able to review in a certain period of time in regard to the backlog studies. However, the Harvard-trained expert retained by my counsel team completely refuted this concern during a meeting with the DA. Specifically, the expert opined that a radiologist, like me, can read a large volume of studies and dictate findings within the periods of time at issue due to the availability of fast, modern radiological PACS technologies. I had no control over the volume of cases he was assigned, or which cases were assigned to him. During the time at issue, I was also providing teleradiology services at other radiology practices (not affiliated with the Practice). The DA investigated those other practices and found no improprieties in connection with my care or billing.

In the end, justice prevailed, and the Practice, along with the ringleaders of the criminal scheme, was rightfully found guilty of a multitude of charges, ranging from enterprise corruption and scheme to defraud to grand larceny and health care fraud. The management team of the Practice, including its owners, faced imprisonment as a consequence of their actions. I want to underscore that I played no part in the scheme orchestrated by the Practice, nor did I reap any financial or non-financial benefits from interpreting the backlogged images. To put it simply, I was entirely unaware of the wrongdoing. It was not until the discovery phase of the legal proceedings that it came to light that the Practice not only had fraudulent handling of the backlog and some other studies from the beginning, but they had used my credentials to submit billings for interpretations that I had never carried out. In essence, I was a victim in this situation. I had placed my trust in the Practice, sharing my credentials without any suspicion, as the Practice had never given me any reason to question their integrity. I had hoped that this truth would be revealed during a trial, but the financial strain imposed by the prolonged legal process, compounded by the challenges posed by the COVID-19 pandemic, made it financially impossible for me to sustain my legal defense with no apparent end in sight.

Following the incident in 2017, the state Medicaid imposed an exclusion that affected both my professional standing and the contractual relationship with my then-full-time employer, as they will not be able to utilize my credentials for billing purposes. This exclusion, in turn, had a cascading effect on my professional affiliations with my existing hospital contracts where I was unable to continue my privileged membership. Furthermore, it is crucial to acknowledge the profound impact this entire ordeal had on my family, my children, my wife, and myself. We experienced severe emotional and financial distress due to the prolonged nature of this case due to the COVID-19 pandemic.

As we entered 2022, determined to clear my name and put this chapter behind us once and for all, my attorney provided an estimate of the substantial legal fees that would be incurred if we were to proceed with a trial. Regrettably, these were expenses that had become unmanageable for me to bear. After enduring several grueling years battling this harrowing situation, my family and I were no longer willing to subject ourselves to further hardship. We were unwavering in our belief in my complete innocence, and upon reviewing the evidence from the discovery process, my legal team was highly confident that a trial would unequivocally vindicate me. Taking into account all the facts and intricate details, my lawyer engaged in discussions with the prosecutor, who, it seemed, was also not inclined towards a trial. Together, they reached an agreement to settle the case, with a paramount focus on ensuring that my medical license remained unaffected. Moreover, my legal team emphasized the nuanced reality that even a trial victory might not necessarily deter the Office of Professional Medical Conduct (OPMC) from pursuing its own procedures. In light of this, my attorney and the prosecutor engaged with OPMC, and a consensus was reached to bring about a resolution that would be favorable for all parties involved. I was assured that my medical license would remain in good standing, enabling me to resume my work as soon as possible. This resolution marked the beginning of closure for my family and me, allowing us to finally move forward from this challenging chapter in our lives.

Given the difficult financial and emotional circumstances and the necessity of safeguarding my medical license, along with the enduring suffering endured by both my family and myself for a period spanning five years, with the potential for even more years of legal battles if I did not take action, I found myself in the regrettable position of having to reluctantly accept a settlement plea deal in December 2022. It is essential to clarify the specifics of this settlement:

• The first aspect of the settlement pertained to the allegation of reading medically unnecessary studies. It is important to note that the determination of medical necessity is the responsibility of the ordering physician, not the radiologist. This fact underscores that I was unfairly implicated in a situation that was beyond my control.
• The second aspect involves providing my credentials to the practice that engaged in fraudulent billing. It is worth emphasizing that as a medical professional, I was obliged to provide my credential information in good faith when working with any practice. Trust is integral to the medical community, and I had no reason to suspect any wrongdoing by the practice at the time.
• The third aspect relates to an alleged false bill to one of the managed care organizations (MCO) insurance, with payment received. It is essential to clarify that I never personally billed any insurance for the practice; rather, the practice itself engaged in false billing using my credentials without my knowledge or consent.

I want to emphasize unequivocally that I maintain my innocence in this matter. I consider myself a collateral victim of the fraudulent activities carried out by the practice. It was a painful decision to accept the settlement, but it was driven by the need to protect my medical license and shield my family from further suffering, as the legal battle loomed ahead. Despite the settlement, I remain steadfast in my belief that I am innocent of any wrongdoing, and I am eager to move forward and resume my medical practice with integrity and dedication.

I have certainly learned a great deal from this ordeal. My experience has underscored the significance of continuous growth and learning. I immersed myself in comprehensive twelve-week CME courses focused on ethics and professionalism, equipping myself with invaluable insights. These lessons emphasized the delicate balance between trust and vigilance. In medicine, trust is paramount, but it must be coupled with a heightened awareness and caution in navigating complex health care landscapes. Moreover, in the midst of that career crisis in 2019, I made a decision to pursue an MSK (Musculoskeletal) fellowship, a choice that not only exemplified my dedication but also ignited my passion for radiology. The experience was not just a means of increasing my expertise; it was a testament to my unwavering commitment to the field. I am currently in the process of seeking Medicaid reinstatement, wherein I intend to provide a comprehensive explanation of the circumstances surrounding the incident. My objective is to transparently convey all relevant facts to the authorities in order to rectify this situation and regain my eligibility. I am committed to ensuring that any misunderstandings or misattributions are addressed appropriately and that I can resume my participation in the program in a lawful and ethical manner. My journey reinforced the importance of continuous learning and ethics. It taught me to balance trust with vigilance. Sharing my experience is not about vindication but highlighting challenges professionals can face unexpectedly. I am now even more committed to patient care and mentoring the next generation of doctors, ensuring they are ethically grounded. These trials have strengthened my dedication to radiology and advancing medical science.

Daniel Cousin is a radiologist.