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Qui Tam

Medicare Fraud 101

Medicare Fraud News, Breaking Headlines and Insight from the Qui Tam Perspective

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Last Entry: February 27, 2013 at 13:11:10

When Unnecessary Medical Treatments Metastasize into Healthcare Fraud

Posted on February 27, 2013
The bedrock rule of government healthcare reimbursements is that providers will only receive payment for medical care that is both ?reasonable? and ?necessary.? It is then up to the sound judgment of providers to define what is truly medically necessary...

Dishonest Hospitals Sidestep Medicare Readmission Penalties by Submitting Claims for Inappropriate Observation Stays

Posted on February 21, 2013
Under Medicare?s Inpatient Prospective Payment System (IPPS), there has always been a recognized problem that hospitals drive up health care costs when they readmit patients who were prematurely discharged. Initially, Medicare regulations monetarily addressed this concern by paying hospitals only one DRG payment for patients admitted twice on the same day with the same symptoms...

DME Providers Continue to Bill Medicare Part B for DME Provided to Skilled Nursing Home Patients

Posted on February 06, 2013
It is common knowledge in the Durable Medical Equipment (DME) industry that a DME provider must not bill Medicare Part B for DME provided to patients in Medicare-certified Skilled Nursing Facilities (SNFs). Indeed, for over twenty years, HHS-OIG has raised concerns that DME providers regularly submit false Medicare Part B claims that misrepresent that their [...

Do Hospital Systems Commit Medicare Fraud When They Set Patient Admission Goals?

Posted on December 05, 2012
Recently, 60 Minutes ran a segment looking into the questionable inpatient admission practices of hospitals owned by Health Management Associates (HMA). According to 60 Minutes, HMA is under federal investigation for pressuring its associated physicians into admitting patients, regardless of medical necessity...

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Medicare Flooded with Improper Therapy Claims

Posted on November 30, 2012
A recent report from HHS-OIG reveals that Medicare paid $1.5 billion in improper claims for skilled nursing care in 2009. This astounding sum represented nearly 6% of the $26.9 billion paid overall to skilled-nursing facilities in 2009. Notably, 25% of all Medicare claims submitted by skilled nursing facilities had ?errors,? and the vast majority of [...

Dishonest Hospitals and Medical Centers Top in Healthcare Fraud Investigations

Posted on November 05, 2012
According to a recent Government Accountability Office (GAO) report, dishonest hospitals and medical facilities are the leading concerns of health care fraud investigations. In civil cases, hospitals were the most frequently investigated subjects, making up 20 percent of the 2,399 subjects, slightly more than medical facilities?defined as medical centers, clinics and practices?at 18 percent...

Government Raises Concerns About Escalating Electronic Health Records Fraud

Posted on October 29, 2012
The federal Stimulus Bill of 2009 launched a Medicare and Medicaid incentive program that encouraged physicians and hospitals to adopt and use certified electronic health record (EHR) systems to improve care and save costs. However, according to a letter the Department of Health and Human Services and the Department of Justice sent to five hospital [...

HCA Allegedly Paid Inflated Rents to Induce Referrals from Medical Practice

Posted on October 19, 2012
In 2007, Thomas Bingham?s company was contacted by HCA to do a market rent study of a medical office suite in Chattanooga, Tennessee. Based on his thorough analysis, Mr. Bingham determined that an equivalent net rental rate of approximately $8.10 to $10...

Government Clamps Down on False E&M Medicare Claims

Posted on October 15, 2012
Medicare reimbursement includes payments for certain evaluation and management (E&M) services that are necessary prior to the performance of a procedure. CMS does not normally allow additional payments for separate E&M services performed by a provider on the same day as a procedure...

Whistleblowers Receive Millions for Uncovering Kickback Scheme between Hospital and Detox Services Management Company

Posted on October 11, 2012
New York Downtown Hospital has agreed to pay $13.1 million to resolve qui tam allegations that it paid illegal kickbacks for patient referrals from a for-profit detoxification services management company. According to the government?s complaint-in-intervention, the hospital paid fees to SpecialCare Hospital Management Corp...

Health Plan Pays Nearly $320 Million for Wrongfully Retaining Overpayment of Medicaid Funds

Posted on September 19, 2012
Because of a 2009 amendment to the False Claims Act, a healthcare provider violates the so-called ?Reverse False Claims Act provision? when it wrongfully retains an overpayment of Government Healthcare funds. Importantly, FCA liability attaches even when the Defendant originally obtained the funds because of a mistake or an error; liability is triggered when the [...

False Claims Act Applies to Medicare Advantage Plans that Provide False Cost Estimates

Posted on September 07, 2012
The Ninth Circuit recently joined the First and Fourth Circuits in holding that knowingly false estimates can trigger FCA liability. Specifically, in United States ex rel. Hooper v. Lockheed Martin Corp., No. 11-5527(9th Cir. Aug. 2, 2012), the Court held that false estimates can trigger FCA liability when the defendant knows the estimates are false [...

Medical Device Companies Potentially Violate the False Claims Act by Selling Knowingly Defective Equipment

Posted on August 03, 2012
A medical device manufacturer pushes its sales force to peddle a device that it knows to be defective. Unfortunately, this particular device is a diagnostic device commonly used by physicians and hospitals across the country for the benefit of Medicare, Medicaid and other Government Healthcare Program beneficiaries...

Medicare Fraud Alert: Ambulance Companies Falsely Billing for Non-Emergency Transport

Posted on July 19, 2012
Medicare’s regulations cover the reimbursement of ambulance services only if the beneficiary?s medical condition dictates that other means of transportation are not advised. These allegations recently surfaced in a successful False Claims Act qui tam action against a medical transport corporation operating in several states, including Alabama and Kentucky...

Medical Device Company Pays $42 Million to Settle Medicare Fraud Allegations

Posted on July 10, 2012
Orthofix International NV, a medical device company headquartered in Netherlands Antilles, has agreed to pay the Government $42 Million to settle allegations stemming from� its marketing of a non-invasive bone growth stimulators Orthofix Spinal-Stim, the Orthofix Cervical-Stim and the Orthofix Physio-Stim...

Medicare Contractors Failed to Identify 76% of Improper Claims for Diabetic Medical Supplies

Posted on June 25, 2012
Medicare Part B covers the cost for home diabetic medical supplies, including blood-glucose test strips and lancet supplies. Typically, Medicare will only pay for 100 test strips per month. To cover additional strips, there must be documentation in the beneficiary?s medical records supporting the specific reason for the additional supplies and documentation in the physician?s [...

Are Hospitals Claiming Inappropriate Observation Stays to Avoid Medicare?s Inpatient Readmission Regulations?

Posted on June 21, 2012
Under Medicare regulations, a hospital is entitled to only one payment if a same-day readmission occurs for symptoms related to the prior stay?s medical condition. This regulation was crafted to deter unnecessary discharges and readmissions solely intended to increase reimbursement...

St. Jude Medical Caught Again: Pays $3.65 Million to Resolve Fraud Allegations

Posted on June 13, 2012
St. Jude Medical, Inc., a leading medical device manufacturer, has become ensnared once again in Medicare fraud allegations: this time settling claims that it inflated the cost of pacemakers and defibrillators purchased by government programs. The Department of Justice has alleged that the company overcharged the Department of Veterans Affairs hospitals and Department of Defense [...

Record Fiscal Year for Health Care Fraud Recoveries!!

Posted on June 08, 2012
Yesterday, Attorney General Eric Holder told the �U.S. House of Representatives Committed on the Judiciary about DOJ?s many accomplishments over the last fiscal year. Relevant to Medicare fraud qui tam cases, �he stated that the DOJ, in cooperation with the HHS and other partners, ?by utilizing authorities provided under the False Claims Act and other [...

How Dishonest Hospitals ?Turbocharge? Their Way to Excessive Medicare Outlier Payments

Posted on May 10, 2012
Outlier payments are reimbursements by the Medicare program to compensate hospitals for extraordinarily costly inpatient cases, as compared to average or typical costs incurred in connection to inpatient care. Congress intended these payments to compensate hospitals only for treating inpatients whose care involves extraordinarily high costs...

Medical Device Executive Pleads Guilty for Orchestrating Kickback Scheme

Posted on April 27, 2012
The federal government has been increasingly saber-rattling about its intention to criminally prosecute high-level executives who steer pharmaceutical and medical device makers into fraudulent waters. A few days ago, the federal government followed through on its tough words, when it obtained a guilty plea from a former vice president of a medical device company for [...

Dishonest CMOs Fraudulently Misallocate Costs to Reduce and Avoid Repayment Obligations to Medicare and Medicaid

Posted on April 20, 2012
A CMO overpayment fact pattern recently came to light in an intervened False Claims Act qui tam case against WellCare Health Plans, Inc. In this case, Wellcare paid $137.5 million to quiet allegations that it falsely inflated the amount it claimed to be spending on medical care in order to avoid returning money to Medicaid [...

Government Recovers $4.1 Billion in FY2011 from Health Care Fraudsters

Posted on April 09, 2012
As the generational wave of baby boomers flows into the Medicare program in the coming years, the pool of government funds exposed to fraudulent schemes will swell. In response, the federal government is increasingly securing the walls of the Medicare Trust Fund, looking for health care fraudsters who are illegally draining Medicare dollars...

Government Cracks Down on Hospitals Billing for Improper Inpatient Stays

Posted on March 14, 2012
Government Healthcare Programs only pay for claims for hospital admissions that are medically necessary. Claims for one-day inpatient stays that are not medically necessary are ineligible for payment and therefore ?false? under the False Claims Act. Much to the chagrin of wayward hospitals, the federal government is increasingly targeting hospitals with disproportionately high one-day stay [...

The Clock Is Ticking for Those Who Wrongfully Retain Medicare Overpayments

Posted on February 03, 2012
On a regular basis, HHS-OIG releases the results of its audits, examining the high rate of overpayments by Medicare contractors. Oftentimes, the Reports include general recommendations and admonishments about how the government should do a better job policing Medicare contractors to avoid overpaying them...

The Whistleblower Effect: How Qui Tam Actions Are Changing the Deterrence Calculus for Hospice Providers

Posted on January 27, 2012
Diakon Hospice, one of the oldest hospices in Pennsylvania, recently paid nearly $11 million to the Federal Government, related to submitting Medicare claims for beneficiaries who were not eligible for hospice benefits under the Medicare regulations. Diakon had voluntarily disclosed the problem to the Government...

Supreme Court Refuses to Undo Seminal Anti-kickback Decision

Posted on January 04, 2012
Recently, the U.S. Supreme Court declined to review a federal appeals court ruling in a closely watched case over whether a defendant can be held liable under the False Claims Act for “causing” health care providers to submit Anti-kickback Statute-violative Medicare claims (Blackstone Medical Inc...

The Justice Department has Recovered a Three-Year Record of Nearly $9 billion for Fraudlent Claims Against the Government

Posted on December 20, 2011
Congressman Chaka Fattah (D-PA) issued a statement today, as the ?top Democratic appropriator? for the Department of Justice: “The Justice Department under Attorney General Eric Holder’s leadership just announced that it has recovered a three-year record of nearly $9 billion for fraudulent claims against the government...

Congressman Fattah Issues Statement Supporting DOJ Fraud Recoveries

HHS-OIG Audit: Health Care Providers Improperly Billed Medicare 75% of the Time

Posted on December 05, 2011
Whether through omission or commission, health care providers regularly overbill Government Health Care Programs. This message has been echoed, time and time again, in audit reports from the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG)...

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