A Virginia doctor and his medical practice have agreed to pay $625,000 to settle a civil fraud case, which accused them of routinely submitting false claims to government healthcare programs.
The United States and the Commonwealth of Virginia alleged that the doctor and his practice falsely billed federal and state payors for balloon sinus dilations that were not medically necessary. The government alleged that they performed these surgeries for many patients even when there was no medical justification for performing the procedures.
The government also claimed that the doctor and his practice staged these procedures, performing each side of the procedure at separate times to increase reimbursement from government payors, again without medical justification. Additionally, the government alleged that they routinely billed for endoscopies with sphenoid sinusoscopy under Current Procedural Terminology Code 31235 even though these procedures were not actually being performed.
The settlement arises from a lawsuit filed under the whistleblower provision of the False Claims Act. The resolutions in this matter resulted from a coordinated effort between the US Attorney’s Office for the Eastern District of Virginia, the Health and Human Services Office of Inspector General, the Department of Defense Office of Inspector General, the Defense Criminal Investigative Service, and the Commonwealth of Virginia’s Office of the Attorney General.
Compliance Perspective
Issue
It is illegal to submit false or fraudulent claims for payment to Medicare or Medicaid. If you know or should know that a claim is false, filing it can result in fines of up to three times the programs’ loss, plus $11,000 per claim. Under the civil False Claims Act, each instance of an item or service billed counts as a separate claim, so fines can accumulate quickly. Facility staff must be knowledgeable about how to report suspicious billing practices. A nonretaliatory environment for reporting these practices is mandatory in all facilities.
Discussion Points
- Review your policies and procedures for preventing and reporting false claims, and for conducting a Triple Check Process to verify the accuracy of Medicare claims. Ensure that 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, including what constitutes a false claim. Provide training to appropriate staff on the Triple Check Process to ensure the accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Document these training sessions and file signed attendance records in each employee’s education file.
- Conduct periodic audits to ensure that all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential violations to their supervisor, the compliance officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is followed monthly before submitting claims to Medicare, and that any identified irregularities are corrected. Review your annual PEPPER (Program for Evaluating Payment Patterns Electronic Report) to ensure your facility is not an outlier for Medicare billing compared to peers. Patterns of concern may indicate either overpayments or underpayments. Use this information as part of your auditing and monitoring efforts to prevent fraud, waste, and abuse of government funds. More information is available at PEPPER Resources (cbrpepper.org).
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
