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Qui Tam

Medicare Fraud 101

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

Post Frequency: 4.5/day

Last Entry: June 28, 2017 at 16:46:39

Genesis Healthcare Inc. Agrees to Resolve Whistleblower Case for $53.6 Million

Posted on June 28, 2017
The Department of Justice recently announced that Genesis Healthcare Inc. will pay $53.6 million to resolve allegations that it and its subsidiaries submitted false claims to government healthcare programs for medically unnecessary therapy and hospice services, and grossly substandard nursing care...

Prestige Healthcare Pays Government for its False Billing Role in Genetic Testing Fraud

Posted on May 15, 2017
Prestige Administrative Services, LLC d/b/a Prestige Healthcare (Prestige), headquartered in Louisville, Kentucky has agreed to pay the United States to resolve genetic testing fraud allegations that it violated the False Claims Act. The Medicare false billing allegations involved unnecessary and fraudulent genetic testing...

Hospital Service Provider Pays $60 Million to Settle Healthcare Fraud Allegations

Posted on March 30, 2017
Recently, the Department of Justice announced that TeamHealth Holdings (successor in interest to IPC Healthcare Inc.) has agreed to pay $60 million to resolve upcoding allegations by billing Medicare, Medicaid, the Defense Health Agency and the Federal Employees Health Benefits Program for higher and more expensive levels of medical service than were actually performed...

Medicare Dollars Are Still Siphoned Through Ambulance Fraud

Posted on February 16, 2017
“Ambulance service companies should be focused on the needs of the patients,? said HHS Office of Inspector General Special Agent in Charge Phillip Coyne. He continued: Billing Medicare for ambulance rides that were unnecessary or at a higher rate than could be medically justified is unacceptable...

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Civil Health Care Fraud Recoveries Have Exceeded $2 billion for the Seventh Consecutive Year

Posted on January 23, 2017
Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department?s Civil Division, announced recently that the Department of Justice obtained more than $4.7 billion in settlements and judgments from civil cases involving fraudulent claims against the government in fiscal year 2016...

Anti-Kickback Statute Reaches Consultants Who Seek to Improperly Influence Healthcare Providers

Posted on October 18, 2016
The vast majority of False Claims Act settlements involving kickback allegations have been instances where healthcare providers have allegedly received kickbacks for utilizing a manufacturer?s product. Recently, however, there have been a few successful recoveries where the alleged kickback recipient was not the ultimate decision-maker or even healthcare provider...

Government Recovers Millions from Hospital System that Allegedly Wrongfully Retained Medicaid Overpayments for Over 60 Days

Posted on September 13, 2016
Recently, the Justice Department announced a first-of-its-kind settlement involving allegations that a health system violated the False Claims Act by retaining Medicaid overpayments for more than 60 days after identifying that overpayments were made. This $2...

Are Medically Unnecessary Tests Driving Growth of In-Office Procedures?

Posted on August 24, 2016
In a recent Wall Street Journal article titled, ?In-Office Testing by Doctors Lifts Medicare Costs,? it was revealed that a sizeable chunk of the Medicare dollars are now going to physicians who utilize newly minted in-office medical devices. In fact, the WSJ?s analysis of recently released Medicare billing data showed that four of the top […] The post Are Medically Unnecessary Tests Driving Growth of In-Office Procedures? appeared first on Medicare Fraud 101.

Are Copayment Assistance Nonprofits to Funneling Kickbacks to Patients?

Posted on July 01, 2016
In recent years, the federal government has reviewed the issue of copayment assistance organizations that purport to help Medicare and Medicaid beneficiaries with their pharmaceutical copayments, but has not yet taken any public enforcement action to our knowledge...

Are Hospitals Pressuring ER Physicians to Inappropriately Admit Patients?

Posted on June 24, 2016
Over the last few years, the government has devoted substantial resources to pursue hospitals that inappropriately admit patients to inpatient stays. This month, the government intervened after initial declaration in a qui tam case against 14-hospital health system Prime Healthcare...

Durable Medical Equipment Fraud Still a Large Problem

Posted on March 09, 2011
Our Medicare system relies on contractors to identify fraudulent claims from the Durable Medicare Equipment (DME) industry. However, time and time again, Medicare contractors have dropped the ball when it comes to identifying even the most egregious instances of fraud...

Inpatient Rehabilitation Facilities Drain Medicare Dollars By Upcoding Transferred Patients As Discharged Patients

Posted on February 18, 2011
Inpatient rehabilitation facilities receive higher Medicare reimbursement payments when patients are discharged, than when the patients are transferred to other facilities. However, according to a recent HHS-OIG report, some facilities have a ?difficult time? distinguishing between discharged and transferred patients...

Medical Device-Maker Allegedly Showed Hospitals How to Cheat Medicare; Hospital Industry Looks to Pass Blame

Posted on February 04, 2011
Medical device-maker Kyphon allegedly trained its sales force to coach hospitals how to improperly schedule and bill kyphoplasty as an inpatient procedure. By billing as an inpatient procedure, the hospitals were able to wrongfully obtain additional government health care dollars for inpatient care that was typically a 1- 2-hour day surgery...

Marcella Auerbach to Speak at the University of Miami Law School

Posted on January 19, 2011
Nolan & Auerbach, P.A. Managing Partner Marcella Auerbach will speak at the University of Miami 2011 Law Review Symposium on Friday February 18, 2011. Ms. Auerbach will discuss the topic of health care fraud during the opening panel discussion. She will be joined in her health care fraud panel by David Hyman, Richard W...

Two St. Louis Hospital Systems Step Forward to Settle False Claims Allegations for $2.2 Million

Posted on January 10, 2011
Two St. Louis-based hospital systems have agreed to shell out more than $2.2 million to quiet allegations that they submitted false Medicare claims for routine foot care procedures. Under the terms of the settlement, St. John’s Mercy Health System and St...

Medicare Paying for Hundreds of Improper Cardiac Stent Implantations

Posted on December 23, 2010
While investigating a doctor who reportedly implanted hundreds of potentially medically unnecessary stents, Senate investigators may have stumbled across a troubling nationwide practice that drains funds from government health care programs and needlessly places patients? lives at risk...

Health Care Providers Must Return Overpayments within 60 Days

Posted on November 30, 2010
Last year, Congress amended the federal False Claims Act to close a ?finders? keepers? loophole, which had permitted health care providers to keep Medicare and Medicaid overpayments. Earlier this year, as part of the Health Care Reform Legislation, Congress set a 60-day time limit for providers to return these overpayments...

Health Care Compliance Officers Are the Frontline Defense to Medicare Fraud

Posted on November 17, 2010
Recently, Nolan & Auerbach, P.A. Partner Joseph E. B. ?Jeb? White was a guest lecturer during the opening session of the George Washington University Healthcare Corporate Compliance Program. This one-of-a-kind program provides a comprehensive corporate compliance education for current or aspiring corporate compliance officers...

CMS Fails to Examine Billing Habits of ?Error-Prone? Providers, Says HHS-OIG

Posted on October 22, 2010
?Where there?s smoke, there?s usually fire.? Law enforcement applies this age-old adage when it focuses investigative efforts on suspicious activity. However, according to a recently released HHS-OIG report, the Centers for Medicare & Medicaid Services (CMS) and its contractors have not been zeroed in on health care providers who have repeatedly submitted incorrect bills to [...

Southern California Medical Center to Pay U.S. $2.2 Million to Resolve Fraud Allegations

Posted on October 06, 2010
A Southern California hospital, El Centro Regional Medical Center, has agreed to pay $2.2 million to settle an FCA qui tam action, alleging that the hospital fraudulently inflated its charges to Medicare patients to obtain larger reimbursements from the federal health care program...

Medicare Paid Millions for Care Supposedly Provided to Dead People

Posted on October 01, 2010
HHS-OIG released the results of an audit it conducted looking into Medicare Parts A and B services billed with dates of service after the beneficiaries? death. Based on its findings, it estimates that Medicare shelled out over $8.2 million in overpayments for Medicare Part B claims with dates of service after the beneficiaries’ deaths...

Whistleblowers Needed to Halt Improper Medicare and Medicaid Payments

Posted on September 24, 2010
Earlier this week, the federal government unveiled proposed regulations to crack down on Medicare and Medicaid fraud by empowering government officials with the power to stop payments as soon as credible fraud allegations are made. Currently, improper health care payments continue to pour out of the federal government coffers, even when credible allegations have been raised [...

Medicare Contractor to Pay $137.5 Million to Settle Health Care Fraud Case

Posted on September 17, 2010
According to a Securities and Exchange Commission filing, WellCare Health Plans has agreed to pay $137.5 million to settle a False Claims Act qui tam action, claiming that the Medicare and Medicaid contractor stole $400 million to $600 million from government health care programs in several states...

Federal Government Auditing the Medical Necessity of the Service Provided to Medicare Beneficiaries

Posted on September 15, 2010
The federal government in part relies on private contractors, known as recovery audit contractors (RACs), to detect fraudulent activity targeting the Medicare systems. Recently, the federal government, through its agency the Center for Medicare & Medicaid Services, decided to expand one RAC?s auditing powers to include medical necessity reviews...

Medicare Overpaid $14 Million Because of Erroneous Place-of-Service Codes

Posted on September 13, 2010
In 2007, the federal government overpaid health care providers by an estimated $14 million because Medicare claims contained erroneous place-of-service codes, according to an HHS-OIG report. Medicare reimburses providers at a higher rate for services provided in a non-facility setting, such as a physician?s office or an independent clinic...

Philadelphia-Area Hospitals Fess Up to Overbilling Medicare and Agree to Pay $7.9 Million

Posted on September 09, 2010
Three Philadelphia-area hospitals self-disclosed to the government that on several occasions, they had improperly billed Medicare for ?one-day inpatient hospital admissions? which should have been billed as ?observations? or ?outpatient visits.? The hospitals agreed to pay the government a total of $7...

California Hospital Pays $5.25 Million to Settle Outlier Billing Allegations

Posted on September 07, 2010
St. John’s Health Center, of Santa Monica, California, has agreed to pay the federal government $5.25 million to settle allegations that it sought inflated Medicare ?outlier? payments. These payments are only intended for extraordinarily expensive medical care, and are not intended to reimburse the hospital for routine procedures...

GOVERNMENT INTERVENES IN SUIT AGAINST ST. JUDE MEDICAL ALLEGING KICKBACKS

Posted on August 09, 2010
The United States Department of Justice announced that it was seeking to intervene in a whistleblower suit alleging that St. Jude Medical, Inc. violated the False Claims Act. The suit, originally filed under the qui tam provisions of the FCA, alleges that St...

Medicare Fraud Strike Force Announces Major Activity Last Week

Posted on July 19, 2010
The U.S. Department of Justice issued a news release last week announcing that ninety-four people have been charged for their alleged participation in schemes to collectively submit more than $251 million in false claims to the Medicare program in the continuing operation of the Medicare Fraud Strike Force in Miami; Baton Rouge, La...

GAO Identifies Five Strategies to Fight Medicare Fraud, Waste, Abuse

Posted on June 17, 2010
On June 15, 2010, the U.S. Government Accountability Office (GAO) released a report identifying five important areas for preventing Medicare fraud, waste and abuse. The strategies in this new report, ?Medicare Fraud, Waste, and Abuse: Challenges and Strategies for Preventing Improper Payments,? are: (1) Strengthening the provider enrollment process and standards; (2) Improving the pre-payment [...

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