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.

From the monthly archives:

September 2010

Whistleblowers Needed to Halt Improper Medicare and Medicaid Payments

by Nolan and Auerbach 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 [...]

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

by Nolan and Auerbach 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. The whistleblower alleges that the company avoided paying [...]

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

by Nolan and Auerbach 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. These intensive audits are designed to [...]

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

by Nolan and Auerbach 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. This higher reimbursement rate helps to [...]

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

by Nolan and Auerbach on September 9, 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 $7.9 million to resolve concerns about the miscoded claims. This is an emerging area [...]

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California Hospital Pays $5.25 Million to Settle Outlier Billing Allegations

by Nolan and Auerbach on September 7, 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. By allegedly turbo charging–raising its charges more [...]

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