Medicare fraud was a major topic of discussion throughout June as several fraud related announcements were made by government agencies followed by a major nationwide arrest of physicians suspected of Medicare fraud. On June 9th, the Inspector General (OIG) for the Department of Health and Human Services (HHS) issued several fraud alerts.
These announcements come after a number of recent legal settlements with doctors for coding irregularities and questionable directorship arrangements. Shortly after the OIG announcement, leaders of the House Energy and Commerce and Ways and Means Committee submitted a letter to the Government Accountability Office (GAO) requesting that it review Medicare’s Fraud Prevention System (FPS). FPS was implemented in July 2011 to detect abnormal or suspicious billing patterns in claims before CMS disburses payments.
The Affordable Care Act (ACA) authorizes $350 million annually for health care fraud prevention and enforcement efforts, which has allowed the Justice Department to hire more. In fact, in the alert that OIG sent on June 12th, there was acknowledgment that the Justice Department is hiring more attorneys to pursue corrupt physicians. Inspector General, Daniel Levinson, relayed the sentiment and hopes that the actions by the Task Force are a warning to other physicians that “fraudulent billing is a high risk approach to lining their pockets”.
The goal of FPS is to avoid the “pay-and-chase” type of fraud detection that resulted in the June 18th simultaneous arrest of more than 200 individuals from several states by Federal authorities. HHS, the FBI and the Department of Justice announced a nationwide arrest of 243 individuals ranging from physicians to beneficiaries. Provider types vary across the board and included home health care providers, psychotherapists, radiologists, durable medical equipment (DME) suppliers and pharmacies. The charges against these individuals range from health care billing and coding fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft. On the physician side, many of the dubious Medicare and Medicaid billings were for up-coding unnecessary services and products that were never rendered to the beneficiaries.
As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.
Kirk Reinitz, CPA