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.

Sheehan Calls for Aggressive Actions against Medicare, Medicaid Fraud and Abuse

by Nolan and Auerbach on April 23, 2009

On April 22, 2009,  New York Medicaid Inspector General James Sheehan testified before the U.S. Senate Committee on Homeland Security and Governmental Affairs Subcommittee on Medicare and Medicaid about waste and fraud.

New York was the most successful state in the nation in Medicaid program integrity in the past year, measured by fraud and abuse recoveries reported to the Centers for Medicare and Medicaid Services (CMS). Still, there are opportunities for significant improvement, especially when it comes to fraud prevention, Sheehan says in the statement.

Sheehan says that for fraud prevention to become reality, there must be a proactive, rather than reactive system-one with oversight, investigative and prosecutive efforts.

One example of how today’s system falls short: the government’s investigations of improper payments, when they involve large organizations and the potential for intentional conduct, tend to fizzle after years of investigation. Eventually, these might result in criminal declination or an indictment, with limited effect on the provider, payment of large amounts of money in a civil settlement, and a corporate integrity agreement to address future conduct. The statement goes on to say: “By the time the settlement occurs, the individuals who were in charge at the time have moved on, and the business models have changed …. [And] the stock goes up.”

The text of his testimony is posted on the OMIG Web site.

http://www.omig.state.ny.us/data/images/stories/press_releases/js_dc_testimony.pdf .

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

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