Medicare Fraud

Every year, we lose billions of dollars to fraud in federal and state health care programs. Every dollar we lose to fraud and abuse is a dollar that is not available to provide home care to seniors, to treat HIV and AIDS, to immunize children, and to discover new treatments for cancer and other diseases. Some fraud schemes even pose a direct threat to the health and safety of patients. Many instances of health care fraud sug­gest that existing control systems do not work the way we imagine they should. Often the manner in which schemes are revealed suggests detection is more luck than system. Whistleblower lawsuits have exposed billing by health care providers for services not rendered, billing for products not delivered, misrepresenting services, unbundling services, billing for medically unnecessary services, duplicate billing, increasing units of service which are subject to a payment rate, falsifying cost reports resulting in increased payment to the health care provider, kickbacks, and on and on. Healthcare fraud is still going strong and this blog is intended to keep readers up to date with all healthcare fraud related news and to provide commentary when warranted. This blog also contains an array of laws and regulations concerning healthcare fraud set out in an easy to read format.

GOVERNMENT INTERVENES IN SUIT AGAINST ST. JUDE MEDICAL ALLEGING KICKBACKS

by Nolan and Auerbach on August 9, 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. Jude made illegal payments to physicians, hospitals, and other health care providers to induce them to prescribe its medical products, including pacemakers and implantable cardioverter defibrillators. Specifically, St. Jude used post-market studies and device registries as mechanisms to pay physicians illegal kickbacks for using its products. The suit also alleges improper payments to physicians for entertainment and travel, including trips to luxury resorts and tickets to sporting events. The lawsuit contends these payments were illegal kickbacks, in violation of the False Claim Act and the Medicare-Medicaid Anti-Kickback Act.

In its motion in support of its motion for intervention, the government stated that it “found good cause to allege that St. Jude caused the submission of false claims by using four post-market programs – the AWARE, ASSIST, and HOUSECALL PLUS studies, and the ACT registry – as kickback vehicles.” The Government plans to file its own complaint by the end of the month.

The whistleblower in this case is represented by Nolan and Auerbach, P.A. To see the Department of Justice memo in support of intervention, click here. For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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Medicare Fraud Strike Force Announces Major Activity Last Week

by Nolan and Auerbach 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.; Brooklyn, N.Y.; Detroit; and Houston. The operation was announced as “the largest health care fraud takedown since Medicare Fraud Strike Force operations began in 2007.”

The joint DOJ-HHS Medicare Fraud Strike Force typically operates independently of qui tam investigations and cases. The Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. More than 360 law enforcement agents from the FBI, HHS-Office of Inspector General (HHS-OIG), multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the operation.

According to the court documents, the defendants participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes, never provided. In many cases, indictments and complaints allege that beneficiaries accepted cash kickbacks in return for allowing providers to submit forms saying they had received the treatments that, in reality, were unnecessary or never provided.

For the full release click here.  For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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

by Nolan and Auerbach 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 review of claims through automated pre-payment claim review; (3) Focusing post-payment claims review on most vulnerable areas; (4) Improving oversight of prescription drug plan sponsors. Develop a robust process to address resolve vulnerabilities to fraud.

The GAO strategies should be implemented by the Department of Health and Human Services and its components, the OIG and CMS. The strategies are intended to ward off fraud before it happens, something which will benefit taxpayers in the long run. Medicare and Medicaid has too long been a pay and chase reimbursement system.

For the GAO Report or information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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Hospitals in Seven States to Pay more than $9.4 Million for Unnecessary Inpatient Kyphoplasties

by Nolan and Auerbach on May 18, 2010

Nine hospitals in seven states will pay the U.S. more than $9.4 Million to settle allegations that the health care facilities submitted false claims to Medicare, the U.S. Department of Justice announced May 17, 2010.

The hospitals are alleged to have overcharged Medicare between 2000 and 2008 when performing kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures. The hospitals performed the procedure on an in-patient, rather than less expensive outpatient basis, in order to increase their Medicare billings.

The settling facilities and the amount being paid by each to the United States are Ball Memorial Hospital, Muncie, Ind. ($1,995,431); Bethesda Memorial Hospital, Boynton Beach, Fla. ($356,079); Bloomington Hospital, Bloomington, Ind. ($1,443,848); Genesys Regional Medical Center, Grand Blanc, Mich. ($931,742); Huntsville Hospital, dba The Health Care Authority of the City of Huntsville, Huntsville, Ala. ($1,992,756); Palmetto Health dba Palmetto Health Baptist Hospital, Columbia, S.C. ($1,861,083.14); St. Elizabeth Medical Center, Utica, N.Y. ($195,976); St. Mary’s of Michigan Hospital, Saginaw, Mich. ($260,065.21); and United Hospital, St. Paul, Minn. ($428,656).

The government settled Medicare fraud cases in 2009 with nine other hospitals for kyphoplasty-related claims, as well as settled for $75 million in 2008 with Medtronic Spine LLC, corporate successor to Kyphon Inc., for causing the Kyphoplasty – related claims. Whistleblowers, or qui tam relators, helped to expose the alleged wrongdoing.

For the full release click here.  For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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OIG Site Recognizes MFCU’s

by Nolan and Auerbach on April 26, 2010

Many Medicare Fraud cases are jointly worked by the feds and the states, as often the cases  are national in scope and involve Medicaid utilization as well as Medicare. To display  the often important role played by State Medicaid Fraud Control Units (MFCUs), the OIG has developed a new section on its website specifically concerning the MFCU’s.  The 50 MFCUs, which are funded on a matching basis as part of the Medicaid program, are established by Federal law as “single, identifiable” Units operated by the States and devoted to the investigation and prosecution of Medicaid fraud and patient abuse and neglect.

For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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Rush University Medical Center to Pay More than $1.5 Million

by Nolan and Auerbach on March 30, 2010

Rush University Medical Center has agreed to pay $1,547,200 plus interest to resolve allegations that the facility violated the False Claims Act, the U.S. Department of Justice (DOJ) announced March 9, 2010. Rush is alleged to have submitted false claims to Medicare during the period 2000 through 2007 by entering into certain leasing arrangements for office space with two individual physicians and three physician practice groups that violated the Stark Law. Office space leased to a referring physician may be considered proper under the Stark Statute, but only if the rent over the term of the lease is consistent with fair market value and is not determined in a way that takes into account the volume or value of referrals or other business generated between the parties. The “Stark Statute” prohibits a hospital (or other entity providing healthcare items or services) from submitting Medicare claims for payment based on patient referrals from physicians having an improper “financial relationship” (as defined in the statute) with the hospital. Rush is one of several defendants in a suit brought in 2004 by two individuals under the whistleblower provisions of the False Claims Act.

For the full press release, go to: http://www.justice.gov/opa/pr/2010/March/10-civ-240.html. For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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Robert Wood Johnson University Hospital to Pay $6.35 Million to Resolve Medicare Fraud Allegations

by Nolan and Auerbach on March 22, 2010

Robert Wood Johnson University Hospital Hamilton, a New Jersey-based hospital, has agreed to pay $6.35 million to settle allegations that the hospital defrauded Medicare, the United States Department of Justice (DOJ) announced March 19, 2010. Two lawsuits filed against the Hamilton, N.J., facility alleged that the hospital fraudulently inflated its charges to Medicare patients to obtain larger reimbursements from the federal health care program.

The two lawsuits were brought under the qui tam, or whistleblower, provisions of the False Claims Act. They alleged that the hospital inflated its charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid, according to the DOJ.

For the full release click here.  For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, PA.

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