Training Programs
Audits & Assessments
Regulatory MonitoringAuthor Archive
Aug
19
Community Health Systems Inc., a Tennessee-based heathcare corporation, allegedly made illegal donations to New Mexico counties that contain three Community Health hospitals, according to an August 10 Albuquerque Journal article.
The suit claims Community Health made donations to the counties to subsidize the state’s Medicaid contributions. The counties then allegedly turned that money over to the state as their Medicaid contribution. Because the federal government pays three times what the state pays for Medicaid, Community Health allegedly received a return on their investment plus triple the amount donated.
The whistleblower suit was filed in 2005 by a former employee, Robert C. Baker. According to the article, Baker learned about the scheme when he took over as revenue manager for Eastern New Mexico Medical Center in Roswell.
Aug
12
State Medicaid Fraud Control Units (MFCU) recovered $1.3 billion in court-ordered restitution, fines, civil settlements, and penalties for fiscal year 2008, according to an August 7 Office of Inspector General (OIG) report.
MCFUs also obtained 1,314 convictions; achieved 971 civil settlements and/or judgments; and excluded 755 providers from participation in the Medicare, Medicaid, and other Federal health care programs in FY 2008, the report stated.
The mission of the MFCUs is to investigate and prosecute Medicaid provider fraud and patient abuse and neglect. Forty-nine states and the District of Columbia have MFCUs—North Dakota does not have an MFCU.
The report highlights a settlement between the New York MFCU and Staten Island University Hospital (SIUH) and SIUH Systems, Inc., in which SIUH agreed to pay the Medicaid program $24.8 million. The settlement resolved allegations that SIUH Systems billed Medicaid for detoxification treatment provided in a special unit of the hospital without a state-issued certificate of operation.
Aug
05
Continuing the trend of increased fraud enforcement, the Medicare Fraud Strike Force arrested 32 suspects in a connection with Medicare fraud schemes that billed the government for medical supplies that were not medically necessary, according to a Department of Justice (DOJ) release.
The bulk of the arrests were made in Houston, where health clinic owners billed Medicare for as much as $4,000 for “arthritis kits”—essentially knee braces, shoulder braces, and heating pads. According to the DOJ, patients said they either did not need the kits or never received them. The strike force also arrested individuals in New York, Boston, and Louisiana in connection with the scheme.
Authorities also broke up a liquid food scam in Houston, in which clinic owners billed Medicare for liquid food (e.g., Ensure) that they never provided to patients. According to the DOJ, some clinics even billed deceased patients.
This major bust comes months after Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced they were adding millions of dollars to the fight against healthcare fraud and abuse. The Medicare strike force has targeted Houston, Miami, Los Angeles, and Detroit as hotbeds for medical fraud and abuse, and has recovered $371 million in false Medicare claims and charged 145 people in just two months.
Jul
29
The Obama administration has made it clear that cracking down on healthcare fraud and abuse is a priority, and the latest version of the America's Affordable Health Choices Act of 2009 includes an additional funding increase to ensure that government money is not lining the pockets of fraudsters.
That increase in enforcement will be essential if more people are covered under a government system, according to Robert A. Wade, Esq., partner at Baker & Daniels, LLP, in South Bend, IN.
Wade says he would expect an uptick in fraud and abuse cases if the reform passes simply because more people will be covered and more money will funnel through the system. If the federal program covers more people, more claims would fall under the False Claims Act and Stark Law.
Some opponents of a government-run healthcare system cite the high level of fraud and abuse in the Medicare and Medicaid programs as a sign that the government is incapable of running an efficient system. However, experts argue that government programs are no more susceptible to fraud and abuse than private insurers.
"If a physician or [healthcare] entity has the capacity to commit fraud, they will do it regardless of which bucket they are taking from," said Wade.
A report from the George Washington University Medical Center in Washington D.C. titled “Health Insurance Fraud: An Overview” concurs.
"What is absolutely clear from virtually every reliable source on the subject is that healthcare fraud is a systemic problem affecting public and private insurers alike, in the individual market, the employer-sponsored group market, and public programs," the report stated.
Authors of the report, Sara Rosenbaum, Nancy Lopez, and Scott Stifler, said the reason the public is more aware of Medicare and Medicaid fraud is because the government is required to tell taxpayers where their money is going. Most recently, Office of Inspector General Chief Counsel Lewis Morris told Congress that the United States lost $60 million to healthcare fraud in 2008, which was 3% of the government's budget.
Private insurance companies are not obligated to release such numbers so fraud involving those companies stays out of the headlines. The amount of money private insurers lost to fraud is reported to the board of trustees, not the public.
Fraud and abuse enforcement is much more significant on the public side as well. Just this year, President Obama allotted $311 million of the $3.4 trillion budget on healthcare fraud and abuse prevention. The Health Care Fraud Prevention and Enforcement Action Team also helped strengthen enforcement.
"[Healthcare fraud enforcement] has been a theme we have seen in the president's budget and Medicare rule making," says Ed Dougherty, senior vice president of B&D Consulting. "I would say regardless of what happens in healthcare reform, there will be increased focus in all sites of service."
Jul
22
Endoscopic Technologies Inc., a medical device manufacturer, agreed to pay the United States $1.4 million to resolve civil claims, according to a Department of Justice release.
The DOJ alleged the company violated the False Claims Act and the Food, Drug, and Cosmetic Act by:
- Marketing its medical devices to treat atrial fibrillation (the most common cardiac arrhythmia or abnormal heart rhythm), a use that is not approved by the FDA
- Promoting expensive heart surgeries using the company’s devices when less invasive alternatives were appropriate
- Advising hospitals to up-code surgical procedures using the company’s devices to inflate Medicare reimbursements
- Paying kickbacks to healthcare providers to use its devices
The whistleblower who filed the case on behalf of the government will receive $210,000 as the statutory share of the settlement.
Jul
15
On July 9, California authorities arrested 20 individuals believed to be involved in a Medicaid fraud scheme that defrauded the Medi-Cal program of allegedly $4.6 million, according to a Department of Justice (DOJ) release.
The most recent arrests bring the total number of defendants connected to the scheme to 42. The DOJ alleges that the 42 defendants and two others conspired to bill the Medi-Cal program for in-home nursing services provided by unlicensed individuals.
The alleged organizer of the ring, Priscilla Villabroza, pleaded guilty to five counts of healthcare fraud last year and admitted that she and others hired unlicensed professionals to provide in-home nursing services to Medi-Cal beneficiaries, many of them children with cerebral palsy or developmental disabilities. Villabroza then billed the program, claiming the unlicensed nurses were licensed vocational nurses (LVN). Villabroza allegedly instructed the unlicensed nurse defendants, some of whom had no medical training, to lie to parents and claim they were LVNs.
According to the DOJ, patients complained about the nurses’ inability to provide care. In one instance, a nurse fled a medical situation, presumably because she was in over her head and unable to administer the proper care.
Jul
08
A report published by the George Washington University Medical Center, Health Insurance Fraud: An Overview, states that the healthcare fraud problem is not specific to public insurers (i.e., Medicare and Medicaid). According to the report’s authors, Sara Rosenbaum, Nancy Lopez, and Scott Stifler, private insurance providers are just as susceptible to fraud as Medicare and Medicaid.
The report states, “What is absolutely clear from virtually every reliable source on the subject is that healthcare fraud is a systemic problem affecting public and private insurers alike, in the individual market, the employer-sponsored group market, and public programs.”
The report also states that medical providers commit 80% of healthcare fraud, consumers commit 10%, and a combination of insurers and their employees commit the final 10%.
The report’s authors argue the reason Medicare and Medicaid appear to be more susceptible to fraud and abuse is because those programs cover the elderly, women, minorities, the less educated, and the poor, who are also the most vulnerable to fraud.
Jul
08
The Louisiana State University Health Sciences Center-Shreveport (LSUHSC) will pay $706,000 to settle allegations that the teaching hospital billed Medicare for services that were not provided, according to an article in the Shreveport Times.
Former LSUHSC employees William Overdyke M.D., a teaching physician in the hospital's orthopedic department, and Susan Belgert Hodnett, the orthopedic head nurse, alleged LSUHSC teaching physicians submitted claims stating they assisted residents in surgical procedures, but were in fact never present during the procedures. According to the article, the physicians and the hospital would then divide the reimbursement.
Overdike and Hodnett filed the charges in October 2002, and according to the article, both whistleblowers were fired within a year of the filing. The False Claims Act protects whistleblowers from being discriminated against by their employers. Overdike and Hodnett will split $141,335 from the settlement and plan to file another suit to collect lost wages, lost benefits, damage to their reputations, and other items allowed by state and federal whistleblower protection laws.
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine
