Healthcare Fraud Is Serious and the Feds Don’t Play
Healthcare practitioners are susceptible to fraud. It can come in many forms, but it is often seen through the need for increased revenue. What seems like a minor fix to earn a couple of extra dollars can turn into a healthcare fraud frenzy.
The CEO of Team Work Ready fraudulently submitted claims for therapy services that were never performed on or received by patients. Patients testified that most of the time, they were left to do exercises alone or with little to no guidance from employees at TWR facilities. At the trial, the CEO was sentenced to over 19 years in prison along with a 14.5 million dollar fine.
People put a great deal of trust and care into healthcare practitioners. Sometimes, greed motivates a practitioner to get as many people in the door, without providing a basic level of care. They can accomplish this by hiring unlicensed medical staff to help in their scheme.
It is important to make sure you are always checking the validity of a potential employee’s credentials and that they are up-to-date with any necessary retraining or recertifications. It saves you time and money in the long run and most importantly -- keeps the patient safe and with proper care.
Telemedicine
Due to COVID-19, there has been a surge in the use of telemedicine in the last year. While this has been monumental in providing healthcare services to many during the pandemic, it has also been a great source of fraud.
In September 2020, the DOJ indicted 86 individuals in healthcare fraud schemes. A recent case involved a physician using telemedicine as a guise to bill for unusually high volumes of DME and related medical supplies.
This is a new area of regulation that is ripe for schemes, so the OIG will be closely following and pursuing any claims that violate the False Claims Act or any CMS regulation.
False Claims Act
The False Claims Act (FCA, for short) prohibits practitioners from submitting insurance claims for lesser yet overpriced goods and services.
Insurance companies and patients place a good amount of trust in practitioners to submit accurate claims, treat them properly, and charge them reasonable prices. The government puts harsh criminal penalties on those who violate FCA for this very reason. It is important to maintain accurate billing practices to prevent inaccuracies such as: charging for undocumented or non-delivered services, overpricing services, and the list goes on.
A great way to avoid an FCA violation is to properly hire and train individuals in medical coding and billing. This ensures they are complying with private and federal-funded insurance programs and your practice is providing quality care at the best prices.
Anti-Kickback Statute and Stark Law
Referral fees from one practitioner to another might seem like a good way to earn a quick buck, but it is a way that can result in serious consequences in the long run.
The Anti-Kickback Statute and Stark Law prohibit medical providers from paying or receiving kickbacks, remunerations, or anything of value in exchange for referrals of patients. These patients typically have their treatment paid by government healthcare programs like Medicare and Medicaid.
It is worth noting that the AKS covers a broad range of services while Stark Law is typically limited to designated health services and applies to a relationship with a physician. Additionally, an AKS violation can trigger an FCA violation as well when it comes to claims submitted to Medicare and Medicaid.
Before these laws were enacted, patients were being seen and treated for unnecessary or very minor problems. The incentive for providers was the high payout for these treatments and in turn, a portion went to the referring provider. Even a hospital offering a physician below market-value rent for office space can be considered a violation of AKS and Stark Law.
Protect Yourself
There are simple steps to do now to minimize your risk of healthcare fraud in the future:
- Create and follow a compliance plan
- Disclose conflicts of interest
- Maintain physician-industry transparency (gifts from pharmaceutical or other medical-based organizations)
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Sources
https://onlinelaw.hofstra.edu/blog/best-practices-for-health-care-providers-to-avoid-fraud/
https://www.natlawreview.com/article/2020-fraud-and-abuse-year-review