Billing for Services Not Covered by Insurance
Facing allegations of health care fraud is daunting. They can carry massive criminal and civil penalties and also pose the risk of loss of reputation in your professional community. They could also affect your ability to continue to practice medicine.
Our attorneys have unmatched experience in handling all types of health care fraud cases, from the initial stages to final settlement. If you face allegations of healthcare fraud, contact one of our knowledgeable healthcare attorneys today for a review of your case.
Health care fraud cases can be complex. A patchwork of federal and state statutes comprise criminal acts regarding health care.
What is “Billing for Services Not Covered by Insurance?”
One common allegation defendants may face is billing for services not covered by insurance. Typically, this involves submitting claims to health care benefit programs for services provided to patients that are not covered under their insurance because they have not met certain requirements.
Below, this article discusses the law used in prosecuting this kind of crime, and actual examples of the scheme. In addition, this article will cover a few potential defenses to allegations of health care fraud.
The False Claims Act (31 U.S.C, Chap. 37, Subchap. III)
Billing an insurance company for services not covered is a violation of United States Law under the False Claims Act, 31 U.S.C, Chap. 37, Subchap. III.
Liability arises when a defendant, to the detriment to the United States Government,
- knowingly presents, or causes to be presented, a false or fraudulent claim for payment;
- knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim;
- conspires with others to commit a violation of the False Claims Act ;
- knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay money or transmit property to the Federal Government.
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Free Confidential ConsultationPenalties for Violating the False Claims Act
A defendant who is found guilty of a violation of the false claims act may be liable for a civil penalty of between $5,000 to $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person. All of the amounts may be adjusted for inflation.
Mitigation
These damages might be reduced to no less than twice the amount of damages if the defendant mitigated their conduct, such as by fully cooperating with the government during the investigation, or providing information to the government before prosecution or legal action occurred. for several reasons, including,
Civil Actions
In addition to the action brought against you by the government, if you have been accused of falsely reporting a diagnosis, you may also be subject to civil actions by a private person, usually an employee or colleague who bore witness to the conduct.
Under 31 U.S.C. §3730, a private citizen may bring an action on behalf of both themselves and the U.S. Government. The government may move to have the case dismissed, may intervene in the case, or may move for extensions of time as is appropriate under U.S. federal civil procedure.
“Qui Tam” or “Whistleblower” Actions
If the government does proceed with the action, they take over the primary responsibility for prosecuting the case, although the private citizen component will still be part of the case. When this happens, it is referred to as a Qui Tam action or a Whistleblower action.
Statute of Limitations
The statute of limitations under the False Claims Act is ten years, meaning a claim must be brought within this time period.
In the News
Florida-based American Sleep Medicine to Pay $15.3 Million for Improperly Billing Medicare and Other Federal Healthcare Program
In January 2013, American Sleep Medicine LLC agreed to pay over $15 million in settlement after being accused of billing several healthcare benefit programs for sleep diagnostic services that were not actually eligible for payment.
American Sleep runs nineteen diagnostic sleep test centers throughout the US. The company’s main business is providing testing to patients suffering from sleep disorders like sleep apnea.
Under federal program requirements (Medicare), in order for a claim for sleep disorder testing to be reimbursable, the initial sleep studies must be conducted by technicians who are licensed or certified by a state or national credentialing body as sleep test technicians.
Allegedly, the claims submitted by American Sleep to Medicare and TRICARE from 2004 to 2011 were false because the diagnostic services were performed by technicians without appropriate credentials.
For more information or the full Department of Justice (DOJ) press release, click this link or copy and paste the URL below.
Manhattan U.S. Attorney Settles Civil Fraud Claims Against Vascular Surgery Clinic and Surgeon for Fraudulently BIlling Medicare for Non-Reimbursable Vascular Surgery Procedures
In May 2015, Mattoo & Bhat Medical Associates, P.C. (“MBPC”) agreed to pay $1,150,000 to resolve claims that they had submitted fraudulent claims for reimbursement by Medicare for vascular surgery procedures which were ineligible for Medicare coverage. MBPC also agreed to enter into an integrity agreement, mandating they implement certain compliance measures and submit to monitoring by the Department of Health and Human Services.
The complaint, filed by the United States Attorney for the Southern District of New York, stated that MBPC routinely required vascular surgery procedures on patients with end-stage renal disease (“ESRD”) even if they presented no clinical necessity for the procedure.
According to the Medicare billing rules in New York State, the monitoring of a dialysis patient’s access site does not require further vascular surgery procedures unless the patient has specific clinic problems.
By scheduling routine vascular surgeries on ESRD patients who did not present clinic necessity and then subsequently billing Medicare for the surgeries, MBPC violated Medicare’s billing regulations.
For more information or the full DOJ press release, click this link or copy and paste the URL below.
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Free Confidential ConsultationCaris Agrees to Pay $8.5 Million to Settle False Claims Act Lawsuit Alleging That it Billed for Ineligible Hospice Patients
In June 2018, Caris Healthcare, L.P. agreed to pay $8.5 million in settlement after they were accused of violating the False Claims Act by submitting false claims for the care of patients who were ineligible for Medicare hospice benefits.
Caris allegedly admitted and re-certified patients for hospice care who were ineligible for the hospice benefit. In order to meet the aggressive admissions goals set by the company, Caris would admit patients that did not have a terminal diagnosis. They would then bill Medicare for the services provided to the patients who were not actually terminal and therefore did not qualify for the Medicare hospice benefit programs.
The suit was brought as a Qui Tam suit by a former employee of Caris. Her share of the settlement will be $1.4 million.
For more information or the full DOJ press release, click this link or copy and paste the URL below.
Potential Defenses to Allegations of Billing for Services Not Covered by Insurance
While there is no universal approach to defending allegations of billing for services not covered by insurance, most cases involve demonstrating that the defendant was without the requisite knowledge or intent to provide false information.
Working at the Direction of Medical Professional
If an employee in a medical office is directed by a medical professional or superior to enter a billing code for a diagnosis that is incorrect, they cannot be held liable for the violation of the False Claims Act. They did not have the requisite intent to defraud an insurance company. In this case, the person directing that employee would be liable for the false reporting of a diagnosis.
Simple Mistake
Under this line of thought, if you made a mistake as to what code needed to be entered or you accidentally hit the wrong key while filling out billing forms, you would not have the requisite intent to make a false claim. If you have made a mistake as to a billing code, you should notify the appropriate person as soon as possible.
Call a Healthcare Attorney You Can Trust
If you have been accused of, or are under investigation for, billing for services not covered by insurance contact an experienced health care attorney as soon as possible. A knowledgeable attorney will also ensure that your right and interests, as well as the rights and interests of your patients, are protected at every stage of the proceedings.