On September 21, 2023, Breon Peace, United States Attorney for the Eastern District of New York, announced a settlement agreement with a Queens-based physician. The settlement agreement addresses allegations that the physician violated the federal False Claims Act by billing Medicare for critical care services to residents of nursing homes when, in fact, he provided only routine care.
The physician provided care to residents of nursing homes that was, for the most part, routine care, such as regular medical checkups. The Government contends that, rather than billing for his services as routine care, the physician billed Medicare for critical care services. Critical care services involve imminent life-threatening deterioration of the patient’s condition. Medicare reimburses healthcare providers at a higher rate for critical care services than for routine care. By billing for critical care services when he provided only routine care, as the Government contends, the physician received extra payment for care that he did not provide.
Under the terms of the agreement with the United States, the physician will pay $1.3 million for conduct that took place in the years 2019 to 2023. In addition to the payment to resolve the government’s fraud claims, the physician has entered into a separate Integrity Agreement with the US Department of Health and Human Services (HHS), Office of Inspector General (OIG). The Integrity Agreement imposes a number of obligations on the physician, all of which are meant to ensure that he complies with Medicare rules and regulations going forward.
Compliance Perspective
Issue
Billing for critical care services while only providing routine care can be seen as fraudulent billing or submission of false claims. It is illegal to submit claims for payment to Medicare, Medicaid, and private insurance 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 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 all Medicare 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.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
