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.

When Durable Medical Equipment Suppliers Fail to Follow the Medical Conditions of Their Patients

by Nolan and Auerbach on October 17, 2011

From patient enrollment to equipment delivery, every single stage of the DME supply process has fallen under the False Claims Act microscope. Increasingly, the government has zeroed in on what we call “set it and forget it” Medicare billing schemes. Here, the DME supplier appropriately approves a Medicare beneficiary to receive a particular DME. However, once the Medicare dollars start flowing, the supplier regularly delivers equipment and supplies whether or not the patient’s need for it continues.

The most recent example of the “set it and forget it” billing scheme was revealed in a $41.8 million False Claims Act settlement involving Hill-Rom Company, Inc., one of the nation’s largest DME suppliers. In this intervened qui tam action, the government alleged that the company had a practice of automatically billing for patients over long periods of time without making any reasonable effort to determine if the patients for whom it submitted the claims continued to meet Medicare conditions for payment. This “set it and forget it” approach to Medicare billing caused the company to submit false claims for patients for whom the equipment was not medically necessary, including claims for patients who had died or were no longer using the equipment.

With DME suppliers regularly relying on automated billing systems, other companies are likely engaged in this same “set it and forget it” billing practice. The whistleblowers in the qui tam action against Hill-Rom Company received $8 million, or nearly 20% of the total recovery.

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

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