A healthcare organization operating a skilled nursing facility in Waco, Texas, and an acute care hospital in the same city have agreed to pay $6,526,851.64 to the United States and the State of Texas to resolve allegations under the Federal False Claims Act and the Texas Health Care Program Fraud Prevention Act.
The United States alleged that the skilled nursing facility submitted claims for medically unnecessary Ultra-High Resource Utilization Group therapy services to federal healthcare programs. The government also claimed that the acute care hospital submitted false claims to federal programs for individual outpatient therapy services at a clinic when group therapy was being provided, and for therapy services at multiple locations where there was no physician-signed plan of care.
Acting United States Attorney Margaret F. Leachman of the Western District of Texas emphasized that healthcare providers will be held accountable for submitting inaccurate claims or seeking reimbursement for unnecessary services. She also encouraged providers who identify improper billing to take proactive steps to resolve the issue, as was done in this case.
The healthcare organization received cooperation credit as part of the settlement, in line with the Department of Justice’s guidelines for voluntary disclosure, cooperation, and remediation in False Claims Act matters. This included disclosing the results of an internal investigation, which led to an overpayment refund to Medicare, voluntarily identifying overpayments for outpatient therapy services, and implementing corrective actions to address the issues identified.
Compliance Perspective
Issue
False claims can arise in various contexts, whether intentional or unintentional. It is essential for healthcare providers to recognize that submitting inaccurate or unsubstantiated claims, such as those for medically unnecessary treatments or services that lack the proper documentation, can lead to significant legal and financial consequences. For example, claims submitted without proper physician orders or without the correct plan of care in place can violate federal and state regulations. Providers who identify such potential violations have the option to voluntarily disclose them through the Department of Health and Human Services (HHS) Office of Inspector General’s (OIG) Provider Self-Disclosure Protocol, helping avoid the costs and disruptions of a government-directed investigation and potential civil or administrative penalties.
Discussion Points
- Review your policies and procedures for preventing and reporting false claims, ensuring that all claims are supported by valid physician orders and the appropriate documentation. This includes implementing a Triple Check Process to verify the accuracy of Medicare claims before submission. Policies should be reviewed at least annually and updated when new regulations or guidance are issued.
- Provide training for all staff upon hire and at least annually on compliance and ethics policies, focusing on what constitutes a false claim and the importance of accurate documentation. Additionally, ensure relevant staff are trained on the Triple Check Process to ensure accuracy in Medicare billing and supporting documents. Members of the compliance and ethics committee should also receive periodic training to stay informed about compliance and ethics issues in healthcare.
- 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.*
