“Billing for Services Not Rendered” (Health Care Fraud)
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Understanding Healthcare Fraud
Health Care is one of the prime topics for the start of a new year. Strong consideration must be given to Health Care Fraud. Millions of dollars are spent each year on health care fraud. Health care fraud impacts areas such as:
- Other government healthcare programs.
The health care arena consists of many players, including:
Mainly, healthcare fraud American has been inundated with various health care professionals engaged in fraudulent schemes. One of the common schemes is billing for services not rendered. Medical providers have made billions of dollars on just billing patients who never knew that they received charges for services they did not get.
Prescribing and overcharging for pain medications. The Opioids epidemic has been attributed to how doctors are writing prescriptions for pain medication without been abreast of its impact on patients.
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Defining Healthcare Fraud
Generally, health care fraud involves a plan or scheme to file a false medical claim in order to make a profit. The primary victims of health care fraud other than the patients are government agencies like:
Health care fraud has a broad scope regarding types of fraud. Healthcare fraud is a billion dollar industry. The number one healthcare fraud is billing for services not provided. Medical providers use this as the primary fraudulently scheme to get over on the government.
Proper Billing Procedure
All medical procedures or services, regardless of medical insurance, will be billed. To keep a record of all medical services rendered, a medical provider must save all the bills related to the patient’s services. In the areas of Medicare and Medicaid, there is a set procedure in place that all medical providers must follow. This means here is no exception to the rule.
Generally, a medical provider sees a patient and provides a bill. The bill is then sent to Medicare for payment. In the age of sophisticated technology, medical providers use an electronic form which has medical procedure codes, which are generally known as HCPCS or CPT codes.
The HCPCS or CPT codes provide Medicare with the medical services that were provided by the medical professional. The medical provider will certify that the information is true and correct. Medicare will, in turn, reimburse the medical providers based on this claim. The problem is there are thousands of claims that Medicare must reimburse.
The reality is that Medicare does not have the manpower or resources to scrutinize every claim. For years, medical providers have been getting rich off of the government by billing for services that were never rendered. In essence, there has been no check and balance system for bills submitted to Medicare.
Medical care providers have an obligation to provide correct and accurate information to the government. In submitting a claim to the federal government, the medical provider is attesting to the fact that the bill is correct for the actual services provided and that they are in compliance with the government requirements for the billing.
Providers need to know some examples of improper claims which consist of:
- Section billing for services not provided
- Section billing for services that are not medically necessary
- Section double billing for services when it has already been included in another bill
- Section billing for services performed by unqualified or improperly supervised
The government has provided a variety of resources for medical providers to make sure that they understand the proper billing procedure along with consequences for falling to due to the enormous amount that the government has to pay; laws have been enacted to protect the government from this fraud.
Laws that Govern Healthcare Fraud
The national government is responsible for Medicare which is America’s largest healthcare program. It is governed by the False Claim Act ( “FCA”). The False Claim Act provides that it is illegal for anyone to submit a “false or fraudulent claim for Medicare reimbursement.
(FT1) The FCA allows an individual with knowledge of Medicare fraud to act on behalf of the Government to recover the fraudulent funds. The wow factor is that as an individual that brings a claim, they are allowed to keep a portion of the recovery.
Further, the FAC entails that the government may intervene or take over the lawsuit and recover three times the damage along with civil penalties which range from $5,000 to $11,000 for each false claim submitted by the defendant.
The Criminal Health Care Fraud Statute
The Criminal Health Care Fraud Statute prohibits anyone from knowingly or willfully executing, or even attempting to execute, a scheme or artifice in connection with the delivery of or payment for health care benefits, items, or services. The services may include such items as :
- Section if anyone defrauds any health care benefit program
- Section if anyone by fraud, false or fraudulent pretense, promise or representation obtains any of the money or property owned by, or under the control of, a health care benefit program
A medical provider charged with violation of the Criminal Health Care Fraud Statute may receive fines, imprisonment, or both.
The Exclusion Statute
The Exclusion Statute is another law that directly impacts those that are convicted of this fraud. It, under the management of the OIG, excludes from participation in all Federal health care programs individuals, and entities convicted of Medicare or Medicaid fraud, and any other offenses related to the delivery of items and/or services under Medicare or Medicaid.
There is a tremendous impact on the convicted Medicare or Medicaid fraud provider. The Exclusion Statute will exclude convicted medical providers, and they are prohibited from participating in Federal health care programs for a designated period.
One of the exclusions for a medical provider is that they may not bill Federal health care programs including, but not limited to, Medicare, Medicaid, and State Children’s Health Insurance Program [SCHIP]) for services he or she orders or performs.
Additionally, an employer or a group practice may not bill for an excluded provider services. At the end of an exclusion period, an excluded individual or entity must seek reinstatement; reinstatement is not automatic.
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The following agencies enforce these laws:
- The U.S. Department of Justice (DOJ)
- The U.S. Department of Health & Human Services (HHS)
- The HHS Office of Inspector General (OIG)
- The Centers for Medicare & Medicaid Services (CMS)
The U. S. Attorney Office along with the FBI work hand in hand to enforce the law regarding health care fraud. It takes a team effort which also consists of the:
- Department of Labor
- Other federal law enforcement agencies
The dedicated unit of the State Medicaid Fraud Unit works in conjunction with all of the other team members. There is one ultimate goal, that is to stop health care fraud.
Consequences of Healthcare Fraud
There are a variety of implications for Health Care Fraud. One example is the exclusion of medical providers from participation in Medicaid, Medicare and any other federal or state health care program.
Civil penalties for violating the FCA may include fines of up to three times the amount of damages sustained by the Government as a result of the false claims, plus up to $21,916 (in 2017) per false claim filed. The severity of the crime will make a difference as to the sentencing. A convicted medical provider can be imprisoned for up to 10 to 20 years.
The fines can range from 10,000.00 to 50,000 per charge. Many times medical providers may be fined up to millions of dollars based on their criminal activity. The medical providers may be subjected to restitution, and they will have to repay the money that was taken.
Impact on the Community for Health Care Fraud
Not only do patients directly suffer due to health care fraud, but society as a whole suffers. The fraud on Medicare and Medicaid has a direct relationship with taxpayers. Medicare is a government entity in which is funded through a tax system. As the cost of Medicare rises due to the fraud, taxes are raised. Everyone feels the pain of the increase in taxes.
Even if you have an employee plan, health care fraud will impact your claim history and premiums that you pay. A self-insured person will also be impacted by healthcare fraud.
The best way to prevent healthcare fraud is education. Medical providers must take the necessary time and energy to become better educated in order to prevent healthcare fraud.
Healthcare fraud is a complex area of law. The complexity of the law makes it vital to have the proper attorney to represent your needs. Our attorneys can provide the necessary guidance in Medicare Law, such as:
- Listening to the client’s concern for your specific case
- Preparing a strategy for you
- Communicating with the appropriate agency
- Representing your interest for the best possible outcome
- Communicating with you to keep you abreast as to all phases of the legal process
- Offering you options for your case
- Preparing your case for trial if necessary
If you want someone who has knowledge, experience, and expertise, you should contact our office. We are here to help guide you to the best possible option based on your needs. You should give us a call. It will be the best decision ever made.