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.

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 quickly than its actual costs were rising–between 1996 and 2003, Saint John’s obtained significant amounts of Medicare outlier payments that it was not entitled to receive, according to the federal government. Several other hospitals have recently settled similar cases under the False Claims Act.

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

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