Government Cracks Down on $225 Million in False Claims

Last week, the Medicare Fraud Task Force brought criminal charges against 111 people including doctors, nurses, and healthcare executives nationwide have been linked to $225 million in false Medicare claims.

The Medicare Task Force is a joint effort between the Department of Health and Human Services, the Department of Justice, and FBI to crack down on Medicare fraud and false claims in an effort to avoid wrongful and wasteful spending.

Actions of the charged individuals include the submission of claims for services and equipment never rendered and the recruitment of patients in order to receive financial kickbacks.

It is reported that since the Task Force started in 2007, it has recovered more than $4 billion. The average prison sentence for those convicted has been 43 months.

To read the full article, click here:
http://articles.latimes.com/2011/feb/17/nation/la-na-medicare-fraud-20110218


Source: Los Angeles Times

OIG Study Examines Medical School Education on Fraud and Abuse

There is and will continue to be more and more investigation into Medicare and Medicaid fraud and abuse which is costing the US taxpayers billions of dollars each year.

One question being discussed is where and when should medical students be provided with instruction on compliance with Medicare and Medicaid laws to prevent fraud and abuse, or is this better left to residency and fellowship training programs?

In the report from the Office of Inspector General (OIG), Department of Health and Human Services, it is reported that Medicare and Medicaid compliance is being provided in medical schools and graduate medical education programs:

44% of medical schools are providing instruction to students

66+% of graduate medical education programs and fellowship programs

The OIG realized that it is difficult for medical schools to incorporate comprehensive education on Medicare and Medicaid fraud and abuse into the medical curriculum. Therefore, it plans to develop educational materials that can be distributed to medical school programs and to engage in conversations with program directors regarding the usefulness of these materials.


To read the full report, click here:
http://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdf

Watch out for H.E.A.T.

The Obama Administration will be increasing the HEAT to help combat healthcare fraud. The US Attorney General and Secretary of Health of Human Services created the Healthcare Enforcement Action Team (HEAT) in 2009 to investigate cases of fraud. HEAT strike teams are currently present in seven cities. The increase will expand HEAT presence to twenty metropolitan areas.

The HEAT strike teams are responsible for targeting and investigating healthcare fraud cases, something that the FBI and Department of Justice have not been able to handle on their own. Billions of dollars are currently being wasted due to fraudulent claims. The Obama Administration hopes that the success of HEAT will help to prevent and recover these claims, so that money can be better spent on improving quality and controlling costs for Medicare beneficiaries.


Source: Lexology (log-in required)
http://www.lexology.com/library/detail.aspx?g=d1c31f72-1a22-41dd-a1b6-84a7f2c46d61&utm_source=Lexology%20Daily%20Newsfeed&utm_medium=Email&utm_campaign=Lexology%20subscriber%20daily%20feed&utm_content=Lexology%20Daily%20Newsfeed%202010-09-03&utm_term

California Doctor Pleads Guilty to Fraudulent Medicare Billing

On April 14, Dr. Glen R. Justice pleaded guilty to five counts of healthcare fraud. In addition to upcoding insurance claims, Justice submitted fraudulent claims to Medicare and other insurers for cancer medications that were never given to patients. (United States v. Justice)

Justice admitted that his scheme took place between 2004 and 2009 and that he had collected payments totalling up to $1 million.

The number of reports of practitioners bilking Medicare and Medicaid continues to grow. This is especially disconcerting in the midst of health reform, since these fraudulent payments are taking up funds that can be used to provide real coverage and care to patients. These fraud cases only highlight the need for better regulation of these programs and safeguards for catching practitioners in the act of fraudulent billing.


Source: BNA

Update: FTC Delays Implementation of Red Flag Rule Until November 1, 2009

The Federal Trade Commission (FTC) has delayed implementation of the "red flag" rule until November 1, 2009. The FTC's announcement does not mention whether or not the rule will be amended to exclude hospitals and other medical facilities from the list of "creditors" who are subject to the rule.

The FTC's announcement and guidance on the red flag rule can be found here:
http://www.ftc.gov/opa/2009/07/redflag.shtm

Source: Federal Trade Commission

FTC Red Flag Rules May Be Delayed Again

The implementation of "red flag" rules requiring creditors and financial institutions to implement security programs and policies to deter identity theft may be delayed once more. Entities are currently required to be in compliance by August 1.

The American Medical Association, American Bar Association, and the National Retail Federation have filed complaints to the Federal Trade Commission (FTC), claiming that the red flag rules are meant for financial institutions such as banks and credit companies. The groups argue that the broad language of the rule has unintentionally placed other institutions under the policy. For example, hospitals would be considered creditors under the rule since they provide services and then defer payment until a patient pays a bill out of pocket, or insurance reimbursement is received.

The organizations have contacted the FTC and Congress to try and get a deadline extension, which would provide time to amend the policy to apply to only the intended institutions. If an extension is not granted, the American Bar Association intends to file a lawsuit against the FTC.


Source: BNA

California Physician Assistant Convicted of Medicare Fraud and Identity Theft

Los Angeles physician assistant Ronald Luis Bradshaw, an employee of Glenmountain Medical Group, was convicted of four counts of healthcare fraud, conspiracy to commit healthcare fraud, and aggravated identity theft on June 30 for stealing a doctor’s identity to collect $7.7 million in Medicare payments (United States v. Bradshaw).

A report by the Department of Justice states that from April 2005 to April 2008, Bradshaw ordered tests and prescribed durable medical equipment to Medicare beneficiaries under the apparent supervision of a doctor.

The doctor testified that he had never worked at the Glenmountain facility and that Bradshaw had written the prescriptions using his UPIN without his knowledge.

The Department of Justice and the Department of Health and Human Services have formed the Health Care Fraud Prevention and Enforcement Action Team (HEAT) to combat fraudulent healthcare claims such as this one. HEAT currently has teams in Los Angeles, Detroit, South Florida, and Houston.

MSPs have the ability to help in the battle against healthcare fraud. When credentialing Allied Health Professionals, ask yourself, “Did I remember to confirm the AHP’s supervising physician?” Also, examine current practices at your facility. Do you have best practices and procedures in place for ensuring that UPINs are kept confidential?

Healthcare fraud is costing the system millions of dollars. By asking yourself the two questions above, you can not only ensure that you have verified the identity of an AHP, but you can also prevent the types of fraud illustrated in this case, which drain funding from the beneficiaries who truly rely on Medicare and Medicaid coverage.

Source: BNA