On August 27, 2024, the US Attorney for the District of Montana announced a settlement agreement between the federal government and a healthcare system based in Helena. The healthcare system has agreed to pay $10,844,201 to resolve allegations under the False Claims Act. The settlement arises from claims that the healthcare system submitted bills to federal healthcare programs based on inaccurate documentation provided by an oncologist.
The settlement asserts that the healthcare system, from January 1, 2015, to December 31, 2020, relied on the oncologist’s documentation and certification to submit claims for higher-level office visits that were not substantiated by the actual services performed. The government contends that these claims were falsified, and that the healthcare system should have recognized the discrepancies. It is also alleged that the healthcare system’s compensation of the oncologist, which was based on these false claims, resulted in a salary that exceeded fair market value.
The settlement agreement credits the healthcare system for voluntarily self-disclosing the misconduct. The healthcare system performed and disclosed the results of an internal investigation, disclosed documents beyond existing business practices or legal requirements, identified individuals who were aware of relevant information or conduct, made officers and employees available for interviews, assisted in determining the losses caused by the misconduct, and enhanced its corporate compliance program.
The program was restructured to strengthen the healthcare system’s compliance practices by appointing a new Corporate Compliance Officer and Committee, implementing a more frequent and robust process to monitor documentation practices and quality measures, establishing a committee to conduct more rigorous audits of physician contracts and compensation, and increasing employee compliance education and training. The healthcare system also transitioned from post-bill to pre-bill audits, which allow the billing and coding team to proactively flag anomalies and work with providers to educate and adjust charges in the billing system.
Compliance Perspective
Issue
Healthcare systems are responsible for the integrity of their claims to federal healthcare programs, even when individual misconduct is a significant factor. Discovery of fraud, waste, or abuse of government funds should be immediately investigated, addressed, and, in collaboration with your compliance attorney, reported using the self-disclosure protocols. Healthcare providers, suppliers, or other individuals or entities subject to Civil Monetary Penalties can use the Office of Inspector General’s (OIG) Self-Disclosure Protocol to voluntarily disclose self-discovered evidence of potential fraud. Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a government-directed investigation and civil or administrative litigation.
Discussion Points
- Review policies and procedures for operating an effective compliance and ethics program and for preventing and reporting false claims and suspicious billing practices. Update as needed.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Provide training to appropriate staff to ensure accuracy of all Medicaid billing and supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of their responsibility to identify compliance and ethics concerns and to promptly report violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
