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.

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Medicaid

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 [...]

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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 [...]

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President’s Proposed 2010 Budget Aims to Increase Revenue by Reducing Fraud, Abuse

by Nolan and Auerbach on February 3, 2010

President Obama’s fiscal year 2010 proposed budget estimates that reducing health care fraud, waste and abuse could save the government about $10 billion in a decade’s time. The budget pledges nearly $1.5 billion for its Health Care Fraud and Abuse Control Program (HCFAC), including a $311 million increase in HCFAC funding. The budget takes aim [...]

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Double-billing Settlement Highlights Whistleblower Concerns

by Nolan and Auerbach on June 23, 2009

Earlier this week, the University of Medicine and Dentistry of New Jersey agreed to pay the federal government $2 million to settle a whistleblower lawsuit alleging that it bilked Medicaid in a double-billing scheme that started in 1993 and ended in 2003, according to the Department of Justice. The settlement was the second time UMDNJ [...]

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UMDNJ to Pay U.S. $2 Million for Allegations of Medicare Fraud

by Nolan and Auerbach on June 9, 2009

The University of Medicine and Dentistry of New Jersey (UMDNJ) has agreed to pay the United States $2 million to resolve federal civil fraud allegations that its hospital defrauded Medicaid, the Justice Department announced June 9, 2009, according to a press release on PR Newswire. From 1993 to 2004, UMDNJ’s University Hospital submitted claims to [...]

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Attorney General and HHS Secretary Announce New Interagency Health Care Fraud Prevention and Enforcement Action Team

by Nolan and Auerbach on May 21, 2009

The government has created a new interagency health care fraud prevention and enforcement team, according to a May 20, 2009 announcement by Attorney General Eric H. Holder, Jr. and Health and Human Services (HHS) Secretary Kathleen Sebelius. The new interagency effort, called the Health Care Fraud Prevention and Enforcement Action Team (HEAT), is charged with [...]

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Wellcare to Pay $80 Million in Medicaid Fraud Case

by Nolan and Auerbach on May 6, 2009

Executives and employees at WellCare Health Plans Inc. engaged in an elaborate scheme to defraud the Florida Medicaid program and the Florida Healthy Kids Corporation, according to a press release by the U.S. Department of Justice. In order to avoid a health care fraud conviction on these charges WellCare must, among other things, consent to [...]

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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 [...]

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Calif. County to Pay U.S. $6.8 Million for Allegations of False Medicare, Medicaid Claims

by Nolan and Auerbach on March 18, 2009

The U.S. Department of Justice announced March 12, 2009, that San Mateo County, Calif., will pay the United States $6.8 million to resolve allegations that the San Mateo Medical Center (SMMC) submitted false claims to the United States in connection with payments from the Medicare and Medicaid programs. The government alleges that SMMC engaged in [...]

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Oops! CMS Paid Millions to Medicare Advantage Plans after Enrollees Died

by Nolan and Auerbach on March 11, 2009

The Centers for Medicare and Medicaid Services (CMS) paid about $4.4 million to Medicare Advantage plans on behalf of enrollees, after those enrollees had died. CMS made the improper payments for 2,657 deceased enrollees between January 2003 and April 2007, according to the March 2009 report “Review of Medicare Payments to Managed Care Plans on [...]

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