Health Care Investigations on the Rise
As a result of health care reform, prosecutions of health care providers are on the rise and we are set to see an explosion of prosecutions in the health care field at the hands overzealous prosecutors.
With the passage of the Affordable Care Act and the current emphasis on decreasing the costs of health care, federal and state governments have increased their efforts to combat health care fraud and abuse.
These efforts, however, easily can ensnare health care providers and others in the industry who made a simple mistake because they were not aware of a new regulation, who themselves were the victims of fraud, or who were unwittingly targeted by aggressive prosecutors.
Some of the most common types of health care fraud - and the ones the federal and state governments are most interested in pursuing - include:
- Billing for services or products that were never received
- Providing and billing for services or products that were unnecessary
- Unbundling services
- Upcoding, or providing one service but then billing for a more expensive service
- Billing for medical equipment that has been returned
- Fraudulently using someone's Medicare or Medicaid card to obtain health care, supplies or equipment
- Insurance companies offering Medicare drug plans that have not received approval from Medicare
- Illegal kick-backs for Medi-Cal billing referrals and other self-referrals
Targets of health care fraud investigations include physicians, medical clinics, hospitals, nursing homes and assisted living facilities, durable medical equipment suppliers, home health agencies, community mental health centers, private insurance companies, and others working in the health care industry.
California Health Care Company Under Investigation
The health care fraud case against Prime Healthcare Services provides an example of the over-zealous prosecutions that are becoming all-too-common.
Prime Healthcare Services, a Southern California company that runs 12 hospitals in the state, is being investigated for health care fraud by the US Department of Justice, Department of Health and Human Services and the California Attorney General's Office. The investigations center on whether an $18 million bill to Medicare for reimbursement of sepsis infection treatments in 2008 was fraudulent.
The rates of sepsis at Prime Healthcare hospitals were nearly three times the national average among Medicare patients. This abnormality led analysts from the Service Employees International Union (SEIU) to speculate that the rates were inflated in an attempt to increase reimbursements. Medicare reimburses hospitals thousands of dollars for treatment of the potentially deadly blood infection.
Prime Healthcare maintains that the billing is accurate and that the higher than national average rates of sepsis are the result of the hospitals' emphasis on early detection and treatment of the infection. Prime Healthcare also claims that the allegations against them were made by members of the SEIU in an attempt to get an upper hand in contract negotiations. The State AG's office, however, has said that they were tipped off to the possible fraud by a different source than the union.
New Health Care Law Gives Government More Power to Prosecute Fraud
The myriad of state and federal rules and regulations for the health care industry can be frustrating for any provider to navigate. With regulations changing continually, it can be nearly impossible for physicians and others in health care to keep up with current laws and fully understand what their legal obligations are day to day.
The passage of the Affordable Health Care Act certainly will not provide any clarity to these obligations, but instead adds another layer of bureaucracy for health care providers to contend with.
The new law also gives the federal government more resources to crack down on suspected Medicare, Medicaid and CHIPs fraud. This includes increasing the criminal penalties for federal health care fraud crimes and giving the Department of Justice increased authority to investigate suspected incidences of health care fraud.
Some of the other changes under the Affordable Health Care Act that health care providers need to be aware of include:
- Requiring mandatory licensing checks for health care providers participating in federal health care programs
- Giving the government the authority to require provider fingerprinting, criminal background checks and on-site visits at health care facilities as preconditions to enrolling in Medicare and Medicaid
- Providing the Secretary of Health and Human Services with the authority to prohibit new providers from joining federal medical benefits programs in order to prevent fraud and abuse
- Allowing the federal government to withhold payment for Medicare and Medicaid services if there is a credible allegation of fraud and a federal investigation is pending
What is missing from this aggressive regulatory scheme and increased emphasis on cracking down on health care fraud is a system of checks and balances to prevent unwarranted federal and state investigations into physicians, clinics and other providers who unwittingly became innocent parties in a bigger fraudulent scheme.
Conclusion
Those who are charged with health care fraud face severe civil and criminal penalties. For example, under California law those convicted of submitting a false claim for a health care benefit may be sentenced up to five years in prison and be ordered to pay a $50,000 fine, or two times the amount of the fraud, whichever is greater.
If you have been charged with or are being investigated for a health care fraud crime, it is important to contact an attorney as soon as possible. Even if you believe you did not do anything wrong, you need a legal representative working on your behalf to help defend against the charges. For more information, contact an experienced white collar crimes defense attorney today.