Know your rights and be ready to assert those rights when the auditors come calling. Most providers think that if you have any documentation problem, you’re going to have to cough up money or maybe even go to jail. But, in fact, the Medicare laws do not require that a service has to be documented in the medical record in order to be reimbursed. Nor are you legally required to use the documentation guidelines. The law only requires you to furnish information to show that you provided the service. So billing for something that isn’t charted in the medical record isn’t, in itself, fraud- if you provided the service.
Healthcare Whistleblower Cases, Tycko & Zavareei, Healthcare Fraud
A number of laws, including the so-called Stark laws and Anti-Kickback laws, generally prohibit the giving of money or other financial incentives (such as gifts) to doctors or hospitals in exchange for referrals or for the prescription of particular pharmaceuticals or supplies. These rules are intended to assure that doctors and other healthcare providers make decisions for their patients based solely upon medical necessity, and not because of some unlawful financial gain. Violations of the Stark and Anti-Kickback laws can result in false claims because, when a provider submits a claim to Medicare or Medicaid, the provider certifies that it has not violated these laws. Thus, if a healthcare provider is receiving kickbacks or is involved in an unlawful financial arrangement, the provider is also violating the False Claims Act, and could be subject to a qui tam lawsuit.
Medicare Fraud Reporting Center
Medicare Whistleblowers are typically healthcare professionals who are aware of hospitals, clinics, pharmacies, Nursing Homes, Hospices, long term care and other health care facilities that routinely overcharge or seek reimbursement from government programs for medical services not rendered, drugs not used, beds not slept in and ambulance rides not taken. If you have information about a person or a company that is cheating the Medicare program (or any other government run healthcare program), you may be able to collect a large financial reward for reporting it here.
85. Medicare Overpayment Cases
B. Medicare Overpayment Cases. Providers of Medicare services, usually nursing homes, are advanced funds by HHS for medically necessary services based on estimates of costs. If data furnished annually by a provider shows the provider was paid more than its reasonable costs for medically necessary services, the fiscal intermediary sends the provider a notice of provider reimbursement explaining the overpayment and demanding reimbursement. If the provider fails to repay the amount owed, HHS collects by offset. See Mt. Sinai Hospital of Greater Miami v. Weinberger, supra; but see In re University Medical Ctr., supra (Medicare offset not permissible in bankruptcy proceedings). [See banksetf.out]. A provider no longer in the Medicare Program may be sued to recover the overpayments. If the provider fails to submit complete accurate cost reports within the designated time there is a presumption that all Medicare payments during the relevant time period were overpayments. See United States v. Upper Valley Clinic Hospital, Inc., 615 F.2d 302, 306 n.8 (5th Cir. 1980). Administrative review of overpayment determinations is permitted for accounting periods ending on or after December 31, 1971, and before June 30, 1973, see 20 C.F.R. §§ 405.1801-1833, formerly 20 C.F.R. §§ 405.490-405.49(I). For accounting periods ending on or after June 30, 1973, see 42 U.S.C. § 11395oo, 20 §§ 405.1801-1889. The provider should be encouraged to seek administrative review of the overpayment claims against it even for earlier periods.
Corning subsidiary pays $119 million and is barred from the Medicare program to settle fraud cases
Dowden and Spear alleged that whenever a doctor ordered a standard blood test, known as a "complete blood count" (CBC), Damon billed Medicare and other insurance programs for additional evaluations known as CBC indices. The government also charged that Damon routinely tacked on unnecessary tests when doctors ordered serial multichannel automated chemistry (SMAC) tests and billed Medicare and other insurance programs separately for them. The company did not bill doctors for these tests, and they were unaware that the federal government and state health programs were paying for them.