A California physician and her former medical practice have agreed to pay $3.8 million to settle allegations that they violated the False Claims Act by knowingly submitting false claims to the Medicare and TRICARE programs.
The physician and her practice claimed to operate an alternative, integrative, and holistic clinic, which was staffed by medical doctors, nurse practitioners, naturopathic doctors, chiropractors, acupuncturists, and mental health professionals, along with ancillary medical and administrative staff. They promoted IV infusion therapy, hormone/supplement therapy, and a variety of other alternative treatments.
The settlement resolves allegations that from 2012 to 2022, the physician and her practice billed Medicare and TRICARE for services that were not covered under either program by disguising the rendering provider, misrepresenting the services provided, “unbundling” services (by billing for a procedure or service in separate parts instead of a single code), or billing for services not medically necessary. In addition to paying $3.8 million to resolve the allegations, the physician will now be excluded from participating in Medicare, Medicaid, and all other federal healthcare programs for five years.
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 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, Inc. for informational purposes only and is not intended to provide legal advice.*
