2013 on Track to Set Record for Health Care Fraud Recoveries Under False Claims Act

October 10, 2013

medicalRecently, we have seen an increase in whistleblower/qui tam cases filed by physicians, nurses or hospital staff employees who have some knowledge of false billing or inappropriate coding taking place. This year appears to be on track to set a record for health care fraud recoveries made by the government under the False Claims Act. The government reportedly collected around $5 billion just from January until July 2013, compared to the $4.9 billion recovered during the entire 2012 fiscal year, according to the Department of Justice (DOJ).

It is obvious that the government has become more aggressive in anti-fraud and recovery efforts. Now that there is money being collected, you can expect their efforts to get worse. Also, since whistleblowers stand to receive up to thirty percent (30%) of a recovery made by the government, plus attorney’s fees and costs, you can expect more whistleblower lawsuits to be filed. Therefore, it is now more important than ever to verify accurate billing and coding.

Common Forms of Health Care Fraud.

Fraud on the government health care programs such as Medicare, Medicaid and TRICARE are particularly rampant in Florida. Providers submitting claims for payment need to pay close attention to these common forms of health care fraud.

Falsifying Records: Submitting claims for services or supplies that were never provided or billing for services that are not demonstrated to be medically necessary.

Upcoding: Billing for an office visit or medical procedure under a code with a higher reimbursement rate than allowed.

Unbundling: Billing related services under separate codes in order to avoid cost savings.

Off-Label Marketing: Marketing pharmaceuticals or medical devices for use in a manner not approved by the U.S. Food and Drug Administration (FDA).

Kickbacks: Providing unlawful monetary payments or other financial incentives to doctors or hospitals in exchange for referrals or for the prescription of particular pharmaceuticals.

Cost Report Fraud: Manipulating or falsifying data submitted to Medicare or Medicaid in cost reports which are used to calculate government reimbursement rates.

Read the 2013-2014 OIG Work Plan.

The best way for Medicare and Medicaid providers to stay informed is to read the Office of the Inspector General (OIG) Department of Health and Human Services (HHS) annual Work Plan. The Work Plan allows the public to see how exactly the OIG plans to enforce Medicare and Medicaid regulations. Of particular importance is the Work Plan’s detailing of particular areas and billing codes and practices that will be under additional scrutiny.  By knowing where the enforcement focus will be, providers can attempt to avoid practices that are likely to lead to Zone Program Integrity Contractor (ZPIC) or Recovery Audit Contractor (RAC) audits. Additionally, a provider that is in a high focus area can prepare for potential audits by beefing up documentation and compliance efforts.

We expect the 2013-2014 Work Plan to be released in October 2013. Be sure to check our website for updates. Click here to read more on the 2012-2013 Work Plan.

Qui Tam Claims Are Usually Filed by Employees.

From our review of qui tam cases that have been unsealed by the government, it appears most of these are filed by physicians, nurses or hospital staff employees who have some knowledge of false billing or inappropriate coding taking place. Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation