Date Posted: Tuesday, March 28, 2023

 

The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

 

ATexas Psychiatrist Settles Claims for Unnecessary Brain Stimulation Treatments

 

A doctor and companies he owned and operated have agreed to pay the United States $3 million to resolve claims they improperly billed to Medicare.

 

Allegedly, the psychiatrist and his companies knowingly and willfully submitted, or caused the submission of, false claims to Medicare.

 

The allegations included intentionally pressuring patients to accept unnecessary medical treatments and billing for those treatments, falsifying treatment records and billing Medicare for services they did not provide.

 

The investigation began when two individuals who worked at one of the clinics filed a qui tam, or whistleblower, lawsuit under seal in 2021.

 

During their terms of employment, they allegedly witnessed patients being pressured to accept unnecessary medical treatments, as well as the falsification of treatment records and billing Medicare for worthless services or services the clinic did not provide.

 

The doctor and his clinics had allegedly submitted claims for payment to Medicare for Transcranial Magnetic Stimulation (TMS) procedures that were not performed, and/or routinely administered without medical necessity or a valid medical purpose. They also billed Medicare for physician assessments when the physician did not see the patient or supervise the TMS session.

 

The complaint indicated the fraudulent conduct continued until the business was sold in April 2022.

 

An FBI Special Agent in Charge on the case stated, "Billions upon billions of taxpayer dollars are stolen by healthcare fraudsters each year."

 

Under the False Claims Act, a private party known as a relator can file an action on behalf of the United States and receive a portion of the recovery.

 

In this case, the relators will receive a total of $300,000.

 

Read the specifics of this case at www.justice.gov.

 

Medical Equipment Company Pays $7 Million To Resolve False Claims Act Allegations

 

A national supplier of durable medical equipment (DME) has paid $7 million to resolve civil allegations that it made false statements in connection with claims for reimbursement it submitted to Kentucky Medicaid, two Kentucky Medicaid Managed Care Organization contractors (MCOs), MO HealthNet (Missouri Medicaid), and D.C. Medicaid.

 

This supplier provides supplies such as hospital beds, manual wheelchairs, power wheelchairs with accessories, and gait trainers. The investigation involved DME that was "manually priced" by Medicaid payers in Kentucky, Missouri, and D.C. Those Medicaid programs reimbursed manually priced DME based on the cost the supplier actually paid the manufacturer for the equipment. Specifically, in Kentucky, reimbursement is based on "a manufacturer’s actual charges" billed to the supplier, or the "invoice price"; in Missouri, reimbursement is based on the "actual invoice of cost"; and in D.C., reimbursement is based on "original documentation reflecting all discounts."

 

In the Settlement Agreement, the United States alleged that the supplier did not disclose all discounts it received, or the cost it actually paid to DME manufacturers when submitting claims for manually priced DME to Kentucky Medicaid, two Kentucky Medicaid MCOs (Aetna Better Health of Kentucky and WellCare of Kentucky), MO HealthNet, and D.C. Medicaid. The supplier’s failure to disclose all discounts, or the actual cost paid, resulted in these Medicaid programs paying it higher reimbursements than it was entitled to receive. The United States contended that the conduct violated the False Claims Act, 31 U.S.C. § 3729(a)(1)(B), a federal law that prohibits knowingly making or using a false statement material to a false claim for reimbursement.

 

As part of the settlement, the supplier also entered into a 5-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General. The CIA requires, among other things, that the supplier implement a centralized risk assessment program, as part of its compliance program, and hire an Independent Review Organization to complete annual reviews of some of its Medicare and Medicaid claims.

 

"By hiding or failing to disclose discounts, to receive higher reimbursement from Medicaid programs across the country, [the supplier] prioritized its financial incentives, to the detriment of these Medicaid programs," said a United States Attorney on the case.

 

The settlement resolves a lawsuit originally brought by a former employee of the supplier under the qui tam, or whistleblower, provisions of the False Claims Act. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. As part of this resolution, he will receive approximately $1.05 million of the settlement amount.

 

The claims resolved by the settlement are allegations only, and there has been no determination of liability. Read more about this case at www.justice.gov.

 

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is the CEO and Principal Strategist for SP Collaborative, serving as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical codes, auditors, and compliance professionals to elevate coding compliance education for the business of medicine.

 

https://spcollaborative.net