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Category Archives: Fraud and Abuse

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What Do Your Coding Statistics Say About You?

Posted in Billing & Reimbursement, Fraud and Abuse

One of the ways the Medicare program and other payer plans are recovering overpayments and identifying billing fraud is through the regular use of data mining.  Simply put, by utilizing software programs that monitor and compare billing and coding data, enforcement authorities are easily able to identify problematic trends in physician billing.  This is an extremely… Continue Reading

Tuomey Case Puts Sharp Emphasis on Fair Market Value in Physician Transactions

Posted in Fraud and Abuse

Earlier this month the closely watched case of U.S. ex rel Drakeford v Tuomey Healthcare System Inc. (675 F.3d 394 (4th Cir. 2012) concluded with a jury finding that the compensation paid to physicians under certain part-time employment agreements by Tuomey Healthcare System resulted in violations of both the federal False Claims Act and the… Continue Reading

Office of Inspector General Guidance on Physician-owned Distributorships “PODs”

Posted in Fraud and Abuse

On March 26, 2013, the Office of Inspector General published much-awaited guidance on physician-owned medical device distributorships (commonly known as “PODs”) in the form of a Special Fraud Alert.  The OIG makes no bones about where it stands on PODs which it describes as “physician-owned entities that derive revenue from selling, or arranging for the… Continue Reading

President Proposes Eliminating Stark In-Office Ancillary Services Exception For Therapy and Advanced Imaging

Posted in Fraud and Abuse

In what would undoubtedly be a devastating blow to many medical practices that rely on the Stark in-office ancillary services exception (which allows physicians to refer within their practices for Stark services), President Obama’s proposed FY 2014 would seek to eliminate the exception for physical therapy, radiation therapy and advanced imaging such as CT and… Continue Reading

DOJ Announces Record Fraud Settlement Against Physician

Posted in Fraud and Abuse, Medicare

Yesterday the U.S. Department of Justice announced that it has entered into a $26M False Claims settlement with a dermatologist in Florida.  According to the DOJ, this is one of the largest False Claims settlements against an individual in history.  The physician was accused of allegedly accepting kickbacks from a pathology lab and billing for medically… Continue Reading

2012 is Record Year for Fraud Recovery

Posted in Fraud and Abuse

The Obama administration announced today that as a result of increased federal health care fraud and abuse enforcement efforts, the federal government recovered $4.2 billion in 2012, setting a new record.  According to the Department of Health and Human Services, for every $1 spent on enforcement efforts, they recouped $7.90.  For more on the topic… Continue Reading

OIG Issues Favorable Advisory Opinion on Free Technology from Hospital

Posted in Fraud and Abuse

Physicians in private practice are increasingly relying upon their local hospitals for assistance in making the transition to full-fledged electronic medical records. The Office of Inspector General (OIG) of the Department of Health and Human Services recently gave the nod to a proposed arrangement which would enhance electronic communication between private practices and a community… Continue Reading

Don’t Ignore Billing and Coding Rules

Posted in Fraud and Abuse

Many physicians were once content (and a few still are) to let their coders select their codes for billing purposes.  At a time when enforcement authorities have some heavy-duty technological weapons for identifying improper billing, physicians can no longer avoid learning the billing rules applicable to their services.  Consider this recent settlement related to the… Continue Reading

Fair Market Value Really Does Matter

Posted in Fraud and Abuse

In my experience, many healthcare providers fail to take seriously the importance of fair market value in their business arrangements.  In fact, one of the most important means of ensuring compliance with federal and state fraud and abuse laws such as the federal anti-kickback and Stark is to ensure that financial arrangements – particularly where there are referrals relationships -are consistent with fair market value. … Continue Reading

Another Record Fraud Bust

Posted in Fraud and Abuse

When it comes to record-breaking Medicare fraud busts, the hits keep coming.  The feds announced today another nationwide takedown of physicians and other healthcare providers for Medicare fraud totaling in excess of $450 million.  All told, 107 people have been charged in this week’s bust for, among other things, submitting false claims to the Medicare program. … Continue Reading

Anatomy of a Healthcare Fraud Bust

Posted in Fraud and Abuse

If you read this blog with any regularity (or even if you read healthcare related news from time to time), you should be aware of the emphasis that federal and state enforcement authorities are placing on healthcare fraud and abuse enforcement.  Despite these intensive fraud and abuse enforcement activities, however, many physicians and healthcare providers… Continue Reading

Feds Announce Largest Single Physician Medicare Fraud Bust

Posted in Fraud and Abuse, Medicare

I have been speaking with physicians for years about the importance of developing effective fraud and abuse compliance programs in their practices and I often still get the same response:  The government is only interested in the big fish like pharmaceutical manufacturers and hospitals -physicians are under the radar.  Well, contrary to popular belief, it appears that there… Continue Reading

Fizzle But Not Much Bang: Medicare Fraud Prevention System Early Results Not Great

Posted in Fraud and Abuse, Medicare

In June of 2011, I reported on this blog about a software program being launched by the federal Department of Health and Human Services to use a technology called predictive modeling to identify fraudulent and abusive billing practices on a prepayment basis.  The program, known as the Fraud Prevention System, was funded through the The… Continue Reading

Federal Prosecutors Continue Focus On Health Care Fraud

Posted in Fraud and Abuse, Medicare

Federal prosecutors continue to focus their efforts on preventing health care fraud, as evidenced by a recent case arising in Texas. Earlier this year, a Houston doctor (Dr. Christina Clardy) was convicted of three counts of mail fraud, 14 counts of health care fraud and one count of conspiracy to commit health care fraud – all relating to over $45 million in false billings to Medicare and Texas’ Medicaid programs.