Star Metrics Fraud Criminal Defense
Our diverse team of lawyers hail from a multitude of backgrounds and experiences. No matter the charges and allegations of healthcare fraud, our team has the skills and resources to provide you with informed advice and thorough representation.
The Healthcare Effectiveness Data & Information system is a widely used performance tool, involving over 184 million people. It is a useful, valid, and reliable way to rate multiple domains of care. These domains include but are not limited to effectiveness, availability, and electronic clinical data of care. Data collected is used to calculate national performance statistics and benchmarks. [1]
If you or someone you know has been charged with healthcare fraud related to falsification of documentation or fraudulent activity, call our attorneys for legal consultation.
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What’s the bottom line?
HEDIS is designed to provide purchasers and consumers with the information needed for reliable comparisons between health plan performances. [2] It helps in the understanding of the quality of care being delivered to patients with the most common chronic and acute illnesses while identifying gaps in health plans. [3]
What is “Star Metrics/Healthcare Effectiveness Data & Information (HEDIS) Fraud”?
“HEDIS” fraud is the manipulation of the quality metrics set forth by the National Committee for Quality Assurance (NCQA). This manipulation can be in the form of falsification of documents and fraudulent information.
What puts a person at risk for prosecution?
Falsified documents include those that have been reformatted as well as those that have been fabricated. Any misleading information can be considered fraudulent.
Example
A registered nurse and home health company owner were convicted of healthcare fraud. The guilty party participated in a $20 million scheme to defraud Medicare. She and her conspirators claimed home health services that were not provided and not medically necessary. Patient records were thus falsified, making this an example of falsified documentation. [4]
Fraudulent Information
Fraudulent information also includes oral statements that are false or misleading. This can consist of an inaccurate reporting of the source of the oral statement. Any attempt to influence the outcome of a HEDIS survey is inappropriate. [5]
Fraudulent, misleading, improper information submitted by organizations as part of their survey process is not tolerated. This can result in admissions, repayments and jail time. It can also result in suspension or denial/revocation of NCQA status. [6]
You may discover more examples of falsified documents and fraudulent information in our “In the News” section below.
What is the False Claims Act (FCA)?
The civil False Claims Act protects the government against false claims made to Medicare or Medicaid. These claims include those that you know should know or are deliberately ignorant of what is false. No specific intent to defraud is needed to be liable.
Penalties
The penalties for submission of false claims may include imprisonment and criminal fines. It can cost you an $11,000 fine per claim along with triple the amount of damages. [7]
Liabilities
Liabilities for false claims include but are not limited to the following:
- Knowingly present false or fraudulent claim(s) for payment or approval
- Knowingly play a role in false or fraudulent statements or claims,
- Delivers less than all money for government use
- Delivers an untrue government document or without completely knowing that the information is accurate
- Conspires to violate one of these rules [8]
Prosecutors Must Prove You Knowingly Committed the Crime
Knowingly presenting false or fraudulent information makes you liable for those acts.
Knowledge of false information is defined as:
- Actual knowledge
- Deliberate ignorance of the truth
- Falsifying information
- Reckless disregard of the truth [9]
HEDIS Fraud In The News:
Article #1: Kaiser Permanente Fined $2.5 Million Over Missing Data Tied to California Medicaid
Charge: False Claims Act violation
Allegations: Missing required data to state’s Medicaid program
California’s officials fined Kaiser $2.5 million after failing to turn over required patient data to Medicaid. More specifically, missing data was from out-of-network care and physician-administered drugs. Reporting deadlines had also lapsed. This was the first time the department had been sanctioned against a Medicaid care plan since 2000.
Repayment of money to the Centers for Medicare and Medicaid Services, which fund the program, was also discussed.
Kaiser worked towards compliance. Sanctions were not related to the quality of patient care or access to treatment. Even still, this was considered fraudulent activity. [5]
To learn more about this case, copy the URL below:
Article #2: Comprehensive Health Services Pays $3.9 Million for Allegedly Double Billing IRS
Charge: False Claims Act violation
Allegations: Billed twice for vision screenings, resting ECGs, collected blood samples
Florida’s Comprehensive Health Services paid $3.9 million after double billing the IRS. This firm was contracted with the IRS Criminal Investigation group for special agent applicants and necessary special agent personnel.
The double billings were in relation to medical examinations, medical surveillance, and health wellness programs.
Although this institution fully cooperated and claimed these over-billing issues were a mistake, this is still considered falsified documentation.
To learn more about this case, copy the URL below:
Article #3: Oklahoma Physician Hit with $580,000 Settlement to Resolve False Medicare Billing Allegations
Charge: False Claims Act violation
Allegations: Oklahoma physician responsible for false claims to be submitted to Medicare for services not provided
The former owner and employee of Blackwell Feet Plus and Feet Plus practices submitted false claims to Medicare. His submissions were of services he did not provide and did not supervise. His National Provider Identifier was allegedly knowingly used for physical therapy services and the billing of Medicare.
To learn more about this case, copy the URL below:
Under investigation for healthcare fraud? CALL US NOW!
844-239-1234
for a Free Confidential Consultation
If you have been charged or are under investigation for defrauding government programs like Medicare or Medicaid, the time to call us is NOW. You may be worried about your career or public reputation.
You may be worried about fines or even jail time. Thus, you need a seasoned, strong legal time to back you. In this rapidly evolving healthcare industry, our team offers integrated services.
We have the resources and the background to fight to protect your constitutional and legal rights.
REFERENCES
[1] https://www.ncqa.org/hedis/[2] https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS.html[3] https://magellanhealthinsights.com/2017/03/15/what-is-hedis-and-what-does-it-mean-to-you/[4] https://www.healthcarefinancenews.com/news/registered-nurse-convicted-20-million-home-healthcare-fraud-scheme-involving-two-agencies[5] https://www.ncqa.org/about-ncqa/contact-us/reporting-fraud/[6] https://www.ncqa.org/about-ncqa/advertising-and-marketing-your-ncqa-status/general-ncqa-advertising-guidelines/[7] https://oig.hhs.gov/compliance/physician-education/01laws.asp
[8] https://www.law.cornell.edu/uscode/text/31/3729
[9] The False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf