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Medicare Fraud News, Breaking Headlines and Insight from the Qui Tam Perspective
From the category archives:
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. However, as healthcare spending has skyrocketed in recent years, academics, patient safety groups, and government [...]
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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. [...]
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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 [...]
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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. For added pressure, HMA supposedly set lofty patient admission goals for each hospital. [...]
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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 [...]
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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. For [...]
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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 [...]
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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 $10.10 per square foot represented fair market value. Much to his surprise, HCA hospital [...]
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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. However, if a provider performs an E&M service on the same day [...]
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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., under purported administrative services agreements. However, the agreements cloaked arrangements for [...]
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