Two Texas mental healthcare providers have agreed to pay $1,083,000 to resolve False Claims Act (FCA) allegations regarding the submission of claims to Medicare, TRICARE, and Medicaid that non-physician personnel rendered, US Attorney Alamdar S. Hamdani announced on July 24, 2024.
From 2017 through 2020, the providers allegedly engaged in a pattern and practice of falsely billing Medicare Part B.
According to the allegations, the providers would submit claims for mental health services that physicians had not rendered or not directly supervised as Medicare regulations require. Some services occurred on dates when the physicians were traveling outside of the United States and thus unable to provide the services. Others allegedly occurred at times when it was not logistically possible for the physicians to have rendered them or directly supervised the services themselves due to the sheer volume of patients at multiple office locations.
Certain non-physician practitioners can provide mental health services but must have their own benefit categories and must bill the government programs directly using their own provider numbers. This did not happen in this case, according to the allegations. As a result of the alleged improper billing, Medicare, TRICARE, and Medicaid reimbursed the providers at the higher physician rate.
“Our federal health care system relies on the fundamental principle that providers bill correctly and adhere to the rules. Taxpayers who fund these programs deserve nothing less,” said Special Agent in Charge Jason E. Meadows of the Department of Health and Human Services – Office of Inspector General (HHS-OIG). “We will continue to collaborate with our law enforcement partners and prosecutors to ensure that those who submit false claims to Medicare are held accountable and that the Medicare trust fund is restored.”
Compliance Perspective
Issue
Submitting false or fraudulent claims for payment to Medicare or Medicaid is illegal. Violators may face fines up to three times the programs’ loss, plus an additional $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or service billed to Medicare or Medicaid is considered a separate claim, so fines can add up quickly. Nursing homes should have comprehensive procedures in place to ensure that services are of an appropriate quality and level and are in fact delivered to residents as ordered and as reported in claims for reimbursement. Moreover, accurate documentation at the time of service is critical to ensuring that billing is fully supported. 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 policies and procedures for preventing and reporting false claims and suspicious billing practices. Update your policies and procedures as needed.
- Train 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. 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.*
