A Texas medical center has agreed to pay the United States $21,637,512 to resolve claims that it improperly billed Medicare, announced US Attorney Alamdar S. Hamdani, on February 22, 2023. Some of the alleged claims were submitted for unauthorized services, services not provided, and services which were deemed so inadequate they were considered worthless.
The medical center was formerly a long-term acute care facility located in Houston that operated as a long-term care hospital. It was in the business of providing extended medical and rehabilitative care to individuals who qualified as clinically complex and possessed multiple acute and/or chronic conditions.
The investigation began when a qui tam, or whistleblower, lawsuit was filed under seal Sept. 28, 2018. The individual filing the suit worked at the medical center’s long-term care facility. During the relator’s employment, they witnessed, among other things, unlicensed, unauthorized students of three different physicians rendering medical procedures. These unauthorized and improper services were fraudulently billed to Medicare. In addition, the medical center submitted claims for payment for services certain treating physicians allegedly rendered. However, records showed those physicians were actually out of the country and could not have performed the services.
Finally, the investigation concluded that from Jan. 1, 2012, through Dec. 31, 2018, the medical center billed for services not supported by the patients’ diagnosis or medical records, and billed for services that were either not rendered or were so inadequate they were worthless (in some cases, resulting in harm to patients). The claims for payment to Medicare for those services were deemed to be fraudulent and submitted in violation of federal law.
“Taking advantage of the elderly and infirm is disgraceful,” said Hamdani. “When providers accept federal funds for reimbursement, they have a duty and responsibility to provide the necessary and best care possible to the patient. As one of the largest of its kind in our district, this settlement shows our commitment to protecting our most vulnerable citizens and the integrity of the Medicare system.”
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. It is also illegal for unlicensed staff to be operating outside of their scope of practice. 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. Also review your policy regarding scope of practice in your facility. 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 Part A billing and supporting documentation before claims are submitted. Ensure that staff understand that failing to deliver care according to facility protocols and standards of practice or failing to follow a resident’s care plan may be considered provision of worthless services. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare. Also train staff on scope of practice. 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. Monitor to ensure that quality care is provided for all residents, with any identified concerns addressed immediately.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
