Medicare Fraud 101 » United States

Inspector general addresses health care fraud

Nolan and Auerbach — Fri, 26 Jun 2009 15:17:32 +0000

On Thursday, June 25, 2009, Daniel R. Levinson presented testimony on the Office of the Inspector General’s (OIG’s) role in addressing health care waste, fraud and abuse, as well as its plans for health care reform.

Talking before the Subcommittee on Health of the House Energy and Commerce Committee Levinson, inspector general of the U.S. Department of Health and Human Services (HHS), said these recommendations were based on OIG’s evaluations, investigations and audits on issues, such as fraudulent activity by health care providers; excessive payments for medical services, equipment, and prescription drugs; and financial conflicts of interests within the institutions charged with protecting the health of the American public.

He emphasized that collaboration and innovation are essential in the fight against fraud. Levinson cited the launch of Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint task force consisting of OIG and Department of Justice senior leadership.

The inspector general identified health care vulnerabilities to fraud and waste and outlined OIG’s program to strengthen the integrity of government-run health care, called the Five-Principle Strategy to Combat Health Care Fraud, Waste, and Abuse.

For the full testimony, go to: http://www.oig.hhs.gov/testimony/docs/2009/06252009_testimony_health_reform.pdf.

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA. http://www.whistleblowerfirm.com/.

Alleged False Claims Act Violations Land Minnesota Hospitals in Hot Water

Nolan and Auerbach — Fri, 22 May 2009 17:06:53 +0000

Three HealthEast Care System hospitals have agreed to pay the United States $2.28 million to settle allegations that the health care facilities submitted false claims to Medicare, the U.S. Justice Department announced May 21, 2009.

According to the DOJ press release, the settlement resolves allegations that the St. Paul, Minn.-based hospitals overcharged Medicare from 2002 to 2007 by thousands of dollars each time they performed kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures that often are due to osteoporosis. The procedure can be performed safely as an outpatient surgery, but the government contends that the HealthEast hospitals performed the procedure on an inpatient basis in order to increase their Medicare billings.

The settlement with HealthEast follows the government’s May 2008 settlement with Medtronic Spine LLC, corporate successor to Kyphon Inc. Medtronic Spine paid $75 million to settle allegations that the company defrauded Medicare by counseling hospital providers to perform kyphoplasty procedures as an inpatient procedure.

The qui tam or whistleblower lawsuit against the HealthEast hospitals was brought under the False Claims Act.

To read the full press release, go to: http://www.usdoj.gov/opa/pr/2009/May/09-civ-497.html.

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

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

Nolan and Auerbach — Thu, 23 Apr 2009 14:26:07 +0000

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.

Government Cracks Down on Violators as Medicare Fraud Increases

Nolan and Auerbach — Thu, 10 Jan 2008 23:09:21 +0000

The federal government is about to announce a national effort to fight Medicare fraud by looking at billing by medical equipment suppliers. There has been an increase in Medicare fraud, particularly in Southern California and South Florida where Medicare are plenty. The crackdown is a nationwide effort by the U.S. Department of Health and Human Services as part of its plan to require medical equipment suppliers to face stricter background checks and inspections with short notice. These Medicare changes are bound to lead to the revocation of Medicare billing privileges and prosecutions for companies engaged in Medicare fraud.

To read the full story click here or on the following for more about Medicare Fraud.

If you believe you have information concerning Medicare fraud and want to read more about Nolan & Auerbach, P.A. you may contact us.

The Decline in FDA Enforcement Activity

Nolan and Auerbach — Mon, 04 Jun 2007 19:06:03 +0000

Congressman Waxman’s United States House of Representatives Committee on Government Reform issued a report entitled “Prescription for Harm/The Decline in FDA Enforcement Activity” in June 2006. Enforcement is down and our FDA-related filings are up. Any relationship?

Has Greed Driven Stent Implantation?

Nolan and Auerbach — Thu, 17 May 2007 22:56:11 +0000

The FBI is apparently investigating allegations that a Maryland cardiologist, Dr. John “Jack” McLean was performing unnecessary stent implantations on his patients. Officials have stated that most of the patients involved are Medicare patients. On average, Medicare pays between $11,184 to $14,287 for a drug-eluting stent procedure. The investigation which involves the FBI as well as the Health and Human Services involves whether the procedures were medically necessary and whether alternative methods could have been used to treat blood clots. Dr. McLean has stated that he has done no wrong and none of his patients are complaining.

To read more click here or visit Nolan Law Firm.

CMS Steps Up Efforts to Ferret Out Fraud -Southern Florida is mentioned

Nolan and Auerbach — Tue, 24 Oct 2006 22:26:11 +0000

CMS recently announced multiple accomplishments and projects, all designed to reduce fraud and abuse: the Los Angeles office of CMS revoked the billing numbers of 117 providers who had presented false claims or suspicious business operations, saving $200 million, editing the system to stop payment on claims using billing numbers from deceased providers saved another $4 million, and targeted efforts against independent diagnostic testing facilities resulted in revocation of the billing privileges of 83 IDTFs and denied $445 million in claims for “beneficiary sharing.”

CMS also announced that it had expanded its satellite offices in Miami and Los Angeles, “providing additional on-the-ground efforts to identify and report fraud, waste and abuse in Medicare.” In addition, activity in the Miami office has included a cooperative federal/state task force on abuses by independent diagnostic facilities investigating complaints and using site visits, record reviews, administrative actions and data analysis. CMS announced that it and the Florida agencies have referred 400 criminal investigations to law enforcement authorities, revoked the licenses and billing privileges of clinics and practitioners, and added edits to the claims system to “auto deny” claims for medically unbelievable services and flag high-volume claims for particular services. CMS further announced that the U.S. Department of Justice has begun 63 criminal cases and 38 civil cases involving Medicare fraud since October 2005.

For more information click here.

South Carolina Medical Center to Pay $3.75 Million Fine

Nolan and Auerbach — Thu, 24 Aug 2006 03:02:50 +0000

As a result of violating Stark Laws and submitting improper bills to Medicare, Medicaid and TRICARE, the Marion County Medical Center in South Carolina will pay $3.75 Million arising out of a qui tam False Claims Act case filed by a whistleblower.

For more information click here.

Are Clinical Drug Studies Being Manipulated?

Nolan and Auerbach — Fri, 28 Apr 2006 22:09:33 +0000

A pharmaceutical company can violate the false claims act by submitting false statements in connection with drug applications and other records to the United States Food and Drug Administration (”FDA”). For example, clinical trial results can involve false statements; and subsequent false statements and claims in marketing materials promoted to the medical community and other health care providers, can cause the submission of hundreds of millions of dollars worth of claims to Government Healthcare Programs in violation of the False Claims Act. This can occur by the misrepresentation of data i.e. overstating a drug’s efficacy or safety in order to generate sales for uses that are marginally effective or even unsafe. These fraudulent acts deceive the FDA and physicians as well as jeopardizing the lives of seriously ill patients.

In the Op-Ed section of the April 25, 2006, Los Angeles Times, Shannon Brownlee suggests that if consumers want honesty, clinical research for drug studies need to be publicly funded. She cites that, “…two-thirds of clinical trials and three-quarters of the papers published in the top medical journals commercially funded, the drug industry has gained unprecedented leverage over what doctors and patients know — and don’t know — about drugs.” While researchers may dispute the implication that their results are manipulated, Ms. Brownlee cites the following: “The recent case of drugs known as atypical antipsychotics is instructive. These new and expensive drugs, with sales of about $10 billion annually, are used to treat serious mental illnesses such as schizophrenia. Earlier this year, the American Journal of Psychiatry published an analysis of 30 separate trials involving head-to-head comparisons of five drugs. Nine out of 10 times, the drug made by the company that funded the study came out on top. When Eli Lilly, the maker of Zyprexa, funded five studies of its drug, Zyprexa was found superior in all five. But when Janssen, the maker of Risperdal, ran its studies, Risperdal came out ahead.”
She suggests that,”.. If we want high-quality medical care, dozens of other drugs — as well as medical devices and non-drug treatments should be subjected to… noncommercial scrutiny.”