Medicare Fraud 101

The Beat Goes On…Fraud Continues at the University of Medicine and Dentistry of New Jersey

Home Health Care Industry Riddled With Fraud

Marietta Diaz, a former employee of Provident Health Care filed a whistleblower lawsuit against her former employer. Diaz claimed that Provident Home Health Care Services, Inc. and Tri-Regional Home Health Care Inc. billed Medicare for home health services that were never provided. Los Angeles Assistant U.S. Attorney Consuelo Woodhead said that this case is not an isolated one and that the home health industry in Southern California has been experiencing serious problems. Woodhead also said this case brought further attention to the scandals in the business. The settlement in this case led to over $33 million being repaid to the government with Diaz receiving over 20.75% of the recovery or $6,847,500.

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

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.

California Home Health Care Provider Pays $33.8 Million to Settle Medicare Fraud Claims

In one of the largest Medicare fraud cases in California history, the owner of Tri-Regional Home Health Care and Provident Home Health Services cheated Medicare of approximately $40 million through a network of paid recruiters and falsification of documents. A payroll clerk working for the company filed a qui tam action in the case after she observed envelopes stuffed with cash and was asked to fill out customer satisfaction surveys for home care that was never provided. In addition, the whistleblower alleged that her employer hired marketers to recruit patients for home health services whether they needed it or not. Doctors were allegedly paid for referrals, and recruiters were paid up to $400 for each enrolled patient. For more information please click here.

Dr. Comfort Shoes in an $18 Million Tight Squeeze

Dr. Comfort Shoes (also known as Rikco International LLC) cannot be feeling too comfortable these days. In March of this year, FBI agents executed a search warrant which was unsealed this week, alleging the company located in Mequon, Wisconsin, cheated Medicare of millions of dollars by claiming diabetic shoes and inserts were approved by Medicare for reimbursement when in fact they were not.For more information please click here.

Pediatrix Pays $25 Million for False Billings for Neonatal Critical Care when Patients not Critically Ill

Pediatrix Medical Group, Inc., a network of physician groups who provide medical services in hospital neonatal intensive care units in 32 states has agreed to pay the government over $25 million to settle government claims under the False Claims Act that Pediatrix improperly billed and upcoded reimbursement claims for more expensive treatment than actually provided. Pediatrix billed the government for critical care services when the infants were not critically ill.

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Medicare Recipient Gets $18,000 Bill for Services Not Rendered Including Infusion Therapy

A sharp Medicare beneficiary says that Medicare was billed $24,653 and paid $17,956 for services not provided. The billings included 15 office visits and $1,000 injections for HIV and AIDS patients; neither of which the beneficiary needed or received. As a matter of fact, he had never been to the West Miami medical center that billed Medicare for services. According to the newspaper article, federal investigators have said that the most expensive and widespread Medicare fraud in South Florida is infusion therapy for persons with HIV and AIDS. For more information click here.

CMS Administrator Mark McClellan Is Leaving to Join Think Tank

In five weeks, CMS Administrator Mark McClellan is going to leave and focus on improving the health care system in the United States. McClellan is leaving a post he held since March 2004. Previously he was the FDA Commissioner from 2002 through 2004. As part of his job McClellan oversees a federal budget of approximately $600 billion.  Several possible successors are being considered for the post.

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Health Care Employers Required to Educate Employees on False Claims Act Whistleblowing

Employee Section 6032 “Employee Education About False Claims Recovery” requires that entities receiving or making more than $5 million in annual payments under a state Medicaid plan,must, as a condition of participation, create written compliance policies designed to educate employees, contractors and agents about false claims, false statements and whistleblower protections under applicable federal and state fraud laws.

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South Carolina Medical Center to Pay $3.75 Million Fine

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.