Task Force Hones in on Medicare Fraud

Three recent criminal actions, which were brought by the Department of Justice and the Department of Health and Human Services' Health Care Fraud Prevention and Enforcement Action Team (HEAT) Task Force underscore the importance of billing and coding accuracy.

Since the formation of the HEAT Task Force in March 2007, approximately 2,900 perpetrators have been charged with various accounts of fraud, which amounts to more than $10 billion in claims to Medicare. Between Aug. 30, 2016 and Sep. 8, 2016, the DOJ released press announcements in three Medicare fraud scheme cases. Two involved physicians and one involved the former owner of a Miami-area home health agency. 

On Sep. 8, a Florida doctor was indicted for "his participation in a $13.8 million health care fraud scheme involving claims for expensive prescription drugs and physical therapy."  The false claims were predicated on allegations that the physician signed fraudulent medical records that authorized medically unnecessary treatment. Furthermore, there was no initial examination or supporting documentation. Hence, these claims were both factually and legally false claims under the False Claims Act.

On Sep. 7, an announcement was made that two clinical psychologists (one from Slidell, La. and the other from Jackson, Miss) pleaded guilty in the U.S. District Court for the Eastern District of Louisiana of one count of conspiracy to commit healthcare fraud. Again, underscoring the focus of the government in preventing and taking action against those who abuse the Medicare system.

"On Jan. 21, 2016, Elbeblawy was convicted after a two-week trial of one count of conspiracy to commit health care fraud and wire fraud and one count of conspiracy to defraud the United States and pay health care kickbacks," the Justice department said in a statement.  The defendants were sentenced on Aug. 30 in U.S. District Court in Miami. Thus, providing another way that individuals are being held accountable – kickbacks.

The key takeaways for physicians include:

- Only bill for work performed;

- Make sure the appropriate codes are being utilized; and

- Think long and hard before taking a kickback in relation to referrals or utilization.

Failure to check these boxes can be costly.