The New York attorney general announced on December 22, 2022, that her office had reached a civil settlement with a doctor and his medical practices, securing more than $2 million for Medicaid. The settlement resolves an investigation by the Office of the Attorney General (OAG) into illegal Medicaid billing practices for vein treatments performed by the doctor.
The OAG found that the doctor had submitted more than 1,000 claims for procedures to Medicaid without sufficient documentation to show what procedures were actually performed or why the procedures were medically necessary, resulting in overpayment of Medicaid reimbursement. As a result of the settlement, the doctor will pay $2,139,037 to Medicaid and he will also withdraw from the New York State Medicaid program.
The OAG found that, between March 2015 and October 2021, the doctor had submitted claims to Medicaid for procedures without adequate documentation. The OAG investigation into these claims found that the doctor’s records did not show which procedures were actually performed, nor did they indicate why the procedures were medically necessary and thus eligible for Medicaid reimbursement.
Compliance Perspective
Issue
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare or Medicaid claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- 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. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of 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 compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected. Review your annual PEPPER (Program for Evaluating Payment Patterns Electronic Report) report to ensure your facility is not an outlier for Medicare billing compared to peers. Patterns of concern may indicate either over payments or underpayments are being received. Use this information as part of your auditing and monitoring efforts to prevent fraud, waste, and abuse of government funds. More information is available at PEPPER Resources (cbrpepper.org).
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
