Filing False or Altered Data Code Sets
A charge of filing false or altered data code sets affect individuals and companies working in the healthcare industry and can lead to substantial fines and penalties.
Our Health Law Group offers its team approach to help defend against charges of healthcare fraud. Attorneys in our Health Law Group have extensive experience defending healthcare professionals, insurance companies, and all related businesses against charges of healthcare fraud, government investigations, and regulatory compliance.
We assist our clients during governmental investigations and advise them on how to comply with constantly-changing regulatory requirements.
If you have been charged with healthcare fraud, consult a healthcare defense attorney as soon as possible.
There are tens of thousands of hospitals, clinics, and private offices along with millions of healthcare professionals and physicians in the United States.
These companies and individuals provide medically-necessary services and treatments to people with illnesses and injuries, and operate in conjunction with several healthcare providers, insurance companies, and federal agencies. These companies vary in size of operations, from small private practices to larger hospitals and institutions.
No matter the size or scope of your company, submitting a false claim for services constitutes a serious offense and could lead to fines, imprisonment, and the revocation of your professional license.
What is “Filing False or Altered Data Code Sets?”
A healthcare provider who submits a proper claim for services or items that were medically necessary is entitled reimbursement. Filing false or altered data code sets, sometimes referred to as “billing and coding errors,” involves intentional misrepresentation of services or items in order to receive a monetary benefit.
Misrepresentations are done by submitting to government benefit programs incorrect Current Procedural Terminology (CPT) codes, billing for services not rendered, altering claim forms for higher payments, etc. Typically, these government benefit programs are Medicare, Medicaid, and Tricare, among others.
The Centers for Medicare and Medicaid Services (CMS) and private insurers rely upon standardized code sets to pay healthcare claims for services and items that are reasonable and necessary to diagnose and treat an illness or injury.
What is a “Code Set?”
The term “code set” refers to any set of codes used by healthcare providers to encode data elements, such as a table of terms, medical concepts, medical diagnostic codes, or medical procedure codes. Code sets are used for documentation and billing purposes for services or items rendered to patient, and are governed within the Code of Federal Regulation.
Who Can Be Found Liable for Filing False or Altered Data Sets?
All healthcare providers and medical professionals who participate in any government benefit program can be found liable for healthcare fraud, conspiracy to commit healthcare fraud, or for violations of federal statute or administrative regulations.
Your participation in these benefit programs subject you to complex regulatory schemes, including a number of specific requirements for obtaining reimbursements for services, supplies, medications, and equipment. These regulations and requirements are constantly changing, and maintaining compliance with the billing requirements requires knowledgeable healthcare law professionals.
Unfortunately, efforts to maintain compliance are not enough. Because billing and coding errors are common, they can trigger expensive federal healthcare investigations. Administrative errors, even honest mistakes, can still lead to federal civil cases with fines reaching $21,916 per false claim. Errors and mistakes include the following:
- Double-billing – Billing either a government benefit program and a private insurer simultaneously or individually for the same services, supplies, medications, or equipment
- Upcoding – Billing for services at a higher rate than the one prescribed by the applicable program reimbursement regulations
- Unbundling – Billing for services at a stand-alone rate rather than at a reduced bundled rate for healthcare services
- Ineligible billing – Billing for costs or services that are otherwise ineligible for federal program reimbursements, such as non-allowable costs, services provided by unlicensed or excluded providers, or medically unnecessary services
In November 2018, two Dallas-area clinic workers were charged in $5.9 million health care fraud scheme. Between 2011 and 2017, Melissa Sumerour and Latosha Morgan conspired to commit health care fraud by engaging in “upcoding” claims filed to the Department of Labor (DOL) for more expensive services than those actually performed, if any at all. Sumerour and Morgan almost exclusively treated DOL employees and routinely billed for higher reimbursable services in order to earn bonuses based on their percentage that their clinic billed.
Companies have also been accused of filing false claims for services performed or altering their patients’ medical records in order to create fraudulent reasons to justify their billing. The Social Security Act requires that claims for services be supported by sufficient documentation to show that care was actually provided. Similarly, maintenance of appropriate medical record documentation substantiating healthcare claims was a required component of all private insurance provider agreements.
What are the Federal Laws Filing False or Altered Data Code Sets?
Title 18 Section 1347 of the United States Codes prohibits healthcare fraud which includes the filing of false or altered data code sets. Other violations of healthcare fraud include the False Claims Act, the Health Care Fraud Statute, and Exclusion Provisions. Violations of these laws may result in nonpayment of claims, Civil Monetary Penalties, exclusion from all federal healthcare programs, and criminal and civil liability.
Generally, claims for filing medical reimbursement are improper and illegal if they are:
- Neither medically reasonable nor necessary
- Billed for higher levels of service than was actually provided
- Billed for higher levels of service than was required by patient’s conditions
- Billed to federal healthcare programs when they should have been billed to another party.
What is the False Claims Act?
The False Claims Act (FCA) imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the federal government. The Act is meant to protect the government from being overcharged or sold substandard goods or services.
Knowledge of the false claim is defined as (1) actual knowledge; (2) deliberate ignorance of the truth; or (3) reckless disregard for the truth. Violations of the FCA may include criminal liability like fines, imprisonment, or both.
What is the Health Care Fraud Statute?
The Health Care Fraud Statute (HCFS) prohibits knowingly and willfully executing, or attempting to execute, a scheme or artifice in connection with the delivery of or payment for healthcare benefits or services to either defraud a healthcare benefit program or to obtain money or property owned or controlled by any healthcare benefit program.
For example, if several doctors and medical clinics conspired in a coordinated effort to defraud Medicare by submitting medically unnecessary claims for power wheelchairs, this would be a violation of the HCFS leading to fines, imprisonment, or both.
What is the Civil Monetary Penalties Law?
The Civil Monetary Penalties Law (CMPL) authorizes monetary penalties for various healthcare fraud violations. The penalty amount depends upon the type of violation. Penalties may include up to three times the amount claimed for each item or service, or up to three times the amount of payment offered, paid, solicited, or received.
Examples of violations of the CMPL include:
- Presenting a claim you know or should know is for an item or service not actually rendered
- Presenting a claim you know or should know is false and fraudulent
- Presenting a claim you know or should know is for an item or service for which Medicare will not reimburse
What are Some Important Cases in Filing False or Altered Data Code Sets?
The United States government brings thousands of healthcare fraud-related cases each year. Charges of filing false or altered data code sets fall under the umbrella of healthcare fraud cases. Listed below are summaries from two cases involving healthcare providers who submitted fraudulent code sets.
Mikes v. Staus–
In 2001, an employee brought a claim against her former employer, a pulmonologist, for submitting ineligible services for reimbursement to Medicare. Although the facts in this case are rather ordinary, it reaffirmed several legal positions in healthcare fraud cases.
The False Claims Act does not define the terms “false” or “fraudulent, but this case upheld previous courts’ interpreted language to require a defendant to have aimed to extract from the government “money the government otherwise would not have paid” to support a claim of healthcare fraud.
This case also supported the position that when a claim expressly states it complies with a particular statute, regulation, or contractual term that is a prerequisite for payment and fails actually to comply, it is considered a fraudulent claim. Lastly, this case furthered the “no medical value” test. When a bill for service is submitted, but the service is “so deficient that for all practical purposes it is the equivalent of no performance at all,” it constitutes a claim for “worthless service” and of “no medical value.”
U.S. v. Jafari –
In 2014, a licensed clinical social worker was found guilty of billing Blue Cross Blue Shield of Western New York for individual psychotherapy sessions of approximately 75-80 minutes. However, the social worker executed her fraud scheme in three different ways.
First, she met with her patients for shorter sessions than the 75-80 minutes required for the CPT code she used.
Second, she met with multiple family members for group therapy sessions yet billed them each for individual sessions.
Lastly, she billed for therapy sessions which never occurred. The federal district court ordered the social worker to forfeit $125,000.00 and was convicted on four of five healthcare fraud charges.
Who is in Charge of Healthcare Fraud Investigations and Prosecutions?
Several government departments and agencies are involved in investigating and prosecuting healthcare fraud. These include, but are not limited to:
- The Federal Bureau of Investigations (FBI)
- The Department of Justice (DOJ)
- The Office of Inspector General (OIG)
- The United States Department of Health and Human Services (HHS)
- The United States Department of Labor (DOL)
- The National Insurance Crime Bureau (NCIB)
- The Coalition Against Insurance Fraud (CAIF)
- The National Association of Insurance Commissioners (NAIC)
- The Medicare Fraud Strike Force (made up of DOJ, FBI, HHS’ Office of Inspector General and individual United States Attorney’s Offices)
- Health Care Fraud Prevention and Enforcement Action (HEAT)
- Medicare Fraud Strike Force (made up of DOJ, the FBI, HHS’ Office of Inspector General and individual United States Attorney’s Offices)
Additionally, under qui tam law, private citizens and entities, known as a “relator,” may also file a civil suit for violations of federal law, which the government can then elect to prosecute. When the federal government does not intervene in a qui tam case, the relator may continue prosecution.
Generally, the DOJ’s Criminal Division, the FBI, the HHS’ Inspector General, and local prosecution work together to investigate and prosecute charges of healthcare fraud, including falsely-filed code sets.
An investigation can include interviews of patients, healthcare providers and professionals, insurance companies, and federal employees.
It also includes audits of your medical records, reviewing your previous claims, and examining physical evidence, such as patient injuries or the accompanying documentation.
What are the Consequences of Being Convicted?
Healthcare fraud is extremely serious, and civil and criminal liability may result in severe penalties. Civil penalties include repayment of claims, non-payment of future claims, exclusion from federal healthcare programs, state disciplinary board hearings, and revocation of your license or hospital privileges. Criminal penalties include up to $250,000, a criminal record, and imprisonment for up to ten years.
Under the Exclusion Provisions, the HHS-OIG has authority to exclude healthcare providers from participating in healthcare programs. Exclusion is mandatory for convictions related to patient abuse, felony convictions related to healthcare fraud, felony convictions related to controlled substances and convictions of program-related crimes.
Exclusion is discretionary for license revocation, convictions related to fraud or obstruction of an investigation or audit, misdemeanor convictions related to controlled substances, and prohibited conduct, such as kickbacks and false statements.
Additional consequences of healthcare fraud may increase the risk of loss of your family, business, personal finances, or time and a tarnished personal or business reputation.
How Can I Defend Myself Against Charges of Filing False or Altered Data Set Codes?
Choosing the right healthcare fraud attorneys can make all the difference. Our health care fraud attorneys provide healthcare defense to clients charged with healthcare violations. Our mission is to help you avoid criminal charges, protect your rights, deter the government’s investigation of you, and to protect your career and reputation.
Federal prosecutors in a criminal case must provide evidence that leaves no alternative logical explanation other than you violated federal healthcare laws. In a civil case, the prosecutor must prove that is was more likely than not you violated federal healthcare fraud laws. In order to be found liable under the False Claims Act, an individual must have had “knowledge” that the claim was false, so the prosecutor will have to prove that you knowingly submitted billing records with the express purpose of defrauding a government agency.
Prosecutors can also try to prove your guilt by showing evidence you knowingly made a materially false or misleading statement in connection with a claim. This means that even if you do not completely fabricate or alter code sets of claims for reimbursement, you may still be found liable for any statement made in connection with the claim if you knew that it would likely mislead a government program or insurance providers.
How We Can Help
We use strategic healthcare fraud defenses, such as the statute of limitations, statutory loopholes and exceptions, misunderstanding, and statutory vagueness.
A statute of limitations is the time period within with an action must be brought against; otherwise, the case will be dismissed. The statute of limitations to bring a claim under the FCA is six years after the violation occurred or three years after the facts material to the claim are known or should have reasonably been known. However, no claim may be filed against you more than ten years after the violation was committed.
Statutory loopholes and exceptions can either mitigate or entirely resolve your healthcare fraud case. Arguing that a violation was a misunderstanding can be used as a defense if it can be proven; however, deliberate ignorance of regulations is not a defense.
A claim that statutory language is void for vagueness is a difficult defense, but prosecutors may be less inclined to bring charges where the relevant administrative or statutory requirements are ambiguous.
Let The Health Law Group Defend You Against Charges of Submitting False or Altered Claims.
“Filing False or Altered Data Code Sets” in the News
Jury Convicts Dallas Anesthesiologist for Fraudulently Billing $10 Million in Health Care Fraud Scheme
Charge: False Claims Act Violation
Allegations: Submitting False Claims for Services Not Rendered
In 2009-10, Dr. Richard Ferdinand Toussaint, Jr. ran a scheme to defraud a number of different health care providers, including Blue Cross Blue Shield of Texas, United Healthcare, the Federal Employees Health Benefits Program, Aetna, Cigna, Humana, and others by submitting, or causing to be submitted, false and fraudulent claims.
Specifically, Toussaint was submitting claims that stated he was personally performing medical direction of anesthesia services for certified registered nurse anesthetists and inflated the amount of time the procedures took and pre-signed patients’ medical records representing the services provided before the procedures even took place.
According to the DOJ press release, prosecutors charged Toussaint with violations of the False Claims Act. To carry out the fraud, Toussaint falsely represented he was “present for” these service, even though at the time these alleged services took place Toussaint was:
- in another state;
- flying on his private jet;
- at another hospital several miles away; and
- under anesthesia and undergoing surgery himself;
Throughout his 18-month-long scheme, Toussaint fraudulently billed health care benefit programs approximately $10 million, according to the government. A federal jury in Dallas convicted Toussaint on all counts, including seven counts of health care fraud.
Chicago Doctor Convicted on Fraud Charges For Billing Insurance Companies For Nonexistent Treatment
Charge: False Claims Act Violations
Allegations: Submitting False Claims for Billing to Insurance Companies for Treatments Never Performed.
From 2005 to 2009, Dr. Paul Madison, an anesthesiologist and pain management specialist, directed the billing staff of an outpatient surgical center to submit false bills to insurers for manipulation-under-anesthesia of body parts that chiropractors had not actually performed.
According to the DOL’s press release, Madison established a scheme to falsify patients’ records to support fraudulent health insurance claim forms. Madison disguised the outpatient surgical centers’ fraudulent billing by creating false medical and billing records using the names, addresses, and dates of birth of patients without their knowledge.
A jury in northern Illinois convicted Madison on all counts.
Article #3: Doctor Charged with Healthcare Fraud and Prescribing Controlled Substances
Charge: False Claims Act Violation and Conspiracy
Allegations: Submitting False Claims for Services Never Performed
In 2018, DEA and FBI investigated Paul Roberts, M.D. with multiple counts of healthcare fraud and conspiracy to dispense controlled substances in northern Alabama. A federal grand jury charged Roberts in a 103-count superseding indictment.
According to the DOJ Press Release, Roberts fraudulently filed data sets for higher billing and conspired to dispense controlled substances without a legitimate medical purpose to defraud third-party administrators of health insurance plans. To carry out that fraud, Roberts billed Blue Cross Blue Shield of Alabama as though he personally saw patients, although delegated that responsibility to staff such as his x-ray technician and office manager.
Roberts faces penalties for health care fraud of up to $250,000 fine and ten years in prison.
Looking for committed attorneys to defend against your healthcare fraud claim?
Charges of defrauding governmental programs can have a devastating impact on you, your family relations, your business, and your future in the healthcare industry.
That is why you need an experienced healthcare professional on your side.
Our attorneys understand the healthcare industry and are motivated to help you understand the charges being brought against you. We can accompany you during the investigatory process to ensure your rights are not violated. Ultimately, our goal is to help you establish a legitimate defense. Our lawyers provide the following services:
- Explanation of the law and the charges being brought against you
- Case assessment, recommendation, and most-likely outcome
- Preparation of an adequate defense, including a winning trial strategy
- Negotiation and communication with the prosecutor
- Protection of your rights throughout the investigation
- Accompaniment to and representation in all legal proceedings
We have the knowledge and experience to successfully defend anyone prosecuted for healthcare and insurance fraud in both state criminal and civil proceedings and federal criminal and civil proceedings.
We have represented industry and corporate clients, doctors, pharmacists, administrators, clinics, hospitals, and all other healthcare industry professionals.
If you, or someone you know, has been charged with healthcare fraud related to filing false or altered data code sets, call our attorneys for a free legal consultation.