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Healthcare fraud and abuse

“During Fiscal Year (FY) 2017, the Federal Government won or negotiated over $2.4B in health care fraud judgments and settlements…$2.6B was returned to the Federal Government or paid to private persons.”

Put this into perspective.  If you were born today and started counting one…two…three…four, you would get to 2B right around retirement age.  This is of course assuming that you don’t sleep.

That’s a lot of money!

What’s important is to read that the money was returned to the government or paid to private persons.  This means that the Government is at least paying this much out to health care providers in order to recover the money at a later date.

There is a saying in health care…”it’s not about how much you make, but how much you keep that matters”.

“In FY 2017, the Department of Justice (DOJ) opened 967 new criminal health care fraud investigations…filed criminal charges in 439 cases.”

Again, I’d love to say that health care is a field full of altruistic people, we we know that some people suck!  They just suck. They take advantage of people.  They may have been bullied as a child and feel the need to get payback.  They may have been the bullies and just continue to try to take advantage of others.  It doesn’t matter the why, but they can’t be trusted to do the right thing when placed in a situation in which personal gain is an option.

“HHS-OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.”

When a health care provider attempts to defraud a federally funded program, the health care provider can be excluded from seeing any patients that participate in these programs.  For instance, if I were to be a shady individual and overbill or bill for services that I didn’t actually provide, the government can then say that I am no longer allowed to see these patients.  The government could also enter into a corporate integrity agreement with the person or company and allow them to see patients, but the company would have to prove that steps are being taken in order to minimize abusing the system.

“Under the joint direction of the Attorney General and the Secretary, the Program’s (Health Care Fraud and Abuse Control Program) goals are:

  1. To coordinate federal, state and local law enforcement efforts relating to health care fraud and abuse with respect to health plans;
  2. To conduct investigations, audits, inspections, and evaluations relating to the delivery of and payment for health care in the United States;
  3. To facilitate enforcement of all applicable remedies for such fraud; and
  4. To provide education and guidance regarding complying with current health care law. “

Imagine that you have the full force of the Federal Government tracking you as a health care professional.  How confident are you that you are doing everything correctly? We are responsible for complying with health care laws and regulations.

It’s unfortunate, but there are many therapists that still struggle with how to bill appropriately and will just take the word of another health care provider instead of looking up the rules and regulations.

“Relators’ Payments: $262,095,000…are funds awarded to private persons who file suits on behalf of the Federal Government under the qui tam (whistleblower) provisions of the False Clams Act”

In my opinion, this is where it gets interesting.  If anyone sees an injustice of abuse or fraud and reports it to the government, the government may pay that person(s) a percentage of what is recovered from the abusing person or company.

About 10% of what was recovered was paid out to individuals and groups that reported this fraud.

Someone is hitting the lottery by doing the right thing and reporting on those that are taking advantage of the system or are ignorant of the rules of the system.

“The return on investment (ROI) of the HCFAC program over the last three years is $4.20 returned for every $1.00 expended.”

If you are the federal government, “would you put more or less money into trying to recover more money from those committing fraud or abuse?”

I don’t see these recovery attempts to slow down over the years.

“Health Care Fraud Prevention and Enforcement Action Team (HEAT)…The Medicare Fraud Strike Force teams are a key component of Heat.  The mission of Heat is:

  1. To marshal significant resources across government to prevent waste, fraud, and abuse in the Medicare and Medicaid  programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.
  2. To reduce health care costs and improve the quality of care by riding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries.
  3. To highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud, and abuse in Medicare.
  4. To build upon existing partnerships between DOJ and HHS, such as our Medicare Fraud Strike force Teams, to reduce fraud and recover taxpayer dollars. “

If you are in healthcare…are you listening?!

Does this sound personal?

This is to crack down on perpetrators costing us billions of Dollars.

“DOJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud an database and increase efficiency in investigating and prosecuting complex health care fraud cases…enables the DOJ and HHS to efficiently identify and target the worst actors in the system.”

As a therapist, you should be shaking in your boots…if you are breaking the rules.  When the DOJ gets involved, it gets serious.

If you aren’t sure if you are one of the “worst actors in the system” you should check out the statistics.

Scary statistics for some

“In January and February 2017, 4 defendants pled guilty…conspiracy to commit health care fraud and conspiracy to commit money laundering…submit false claims to Medicare and Medicaid for among other things, fraudulent physical and occupational therapy services…patients received medically unnecessary services that were later falsely billed to Medicare and Medicaid…totaling over $55 million were submitted to Medicare and Medicaid in connection with the scheme”

This may be more than most people can perceive regarding fraud, but it doesn’t always start this way.  I’ve heard that it starts with overcharging by a couple of minutes and when a person doesn’t get caught, then the billing becomes more and more unethical.  Before you know it, the person is billing for thousands of dollars of services that weren’t actually performed.

“In March 2017, an owner of several physical and occupational therapy clinics in the Central District of California was sentenced to 5 years and 3 months in prison after pleading guilty to health care fraud conspiracy…ordered to pay more than $2.4 million in restitution to Medicare…instructed therapists and others to bill Medicare for physical and occupational therapy services that were medically unnecessary and not provided”

This is unfortunately all to common.  I received calls just in the past year from PT;s in Minneapolis, Houston, NYC, and San Diego describing similar situations.  This is happening all across the country, but very few people are saying anything about it.  It is much easier to ask opinions of others that have no vested interest in the topic than it is to actually call the compliance officer for the company or call the office of inspector general.

“In July 2017…a 2-count indictment against 5 high-billing medical professionals who worked at a network of Brooklyn-area clinics where patients were paid illegal kickbacks in return for subjecting themselves to purported physical and occupational therapy, diagnostic testing and other medical services.”

Kickbacks are illegal.  Kickbacks come in many forms.  Money is the easy one, but there are others.  I’ve heard of free sports tickets, free trips to medical conferences, paying patients to show up for sessions, waiving co-pays for all patients in order to keep them in the clinic, etc. etc. etc.

If you are a patient, this is illegal and needs to be reported.  If you are a therapist, this is illegal and needs to be reported.

“In October 2016, the owner and medical director of Christian Home Health Agency in New Orleans were sentenced to 8 years and 6 years in prison, respectively, after being convicted of health care fraud for billing Medicare for home health services that were not medically necessary or were not provided.”

People go to prison.  Some worry about whether they will be shunned by their job, so they don’t report the wrongs noted in the clinic.  Some people worry about whether they will lose their job, so they don’t report it.  People are going to prison.  Jobs come and go, but time served isn’t something that one can just walk away from.  Walk away from a negative situation while you still have time…or you may find yourself doing time.

To see the report in whole click here

To learn more click here.

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Categories: Physical therapy, PTs, Written BlogsTags: ,

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