Medicare fraud

All posts tagged Medicare fraud

Latest Developments: Medicare Appeal Backlog Litigation

by admin on July 3, 2018 No comments

medicare appealBy: Matt Fischer

In 2012, the American Hospital Association (AHA) along with three member hospitals filed a lawsuit against the U.S. Department of Health and Human Services (HHS) for the agency’s failure to meet the 90 day decision requirement at the Administrative Law Judge (ALJ) level known as the Office of Medicare Hearings and Appeals (OMHA).  Through the years, the case has moved back and forth between a federal district court and federal appeals court in the District of Columbia.  Most recently in March, a federal district court judge ordered the AHA to expand on its suggestions it has made over the course of its litigation for how HHS can clear the ever-growing backlog and additionally, explain why the current procedures are insufficient.

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Cutting Patients a Break: Your Financial Hardship Policy

by admin on October 11, 2013 No comments

financial hardshipBy David Hirshfeld

with Jean Acevedo, Guest Contributor

As premiums and deductibles rise and coverage shrinks, more and more patients have difficulty paying for their health care.  You can provide financial relief to your patients if you wish, but you should only do so in accordance with a uniform hardship policy.

As a general rule, the practice should not routinely waive co-pays or deductibles, or offer discounts based on a patient’s statement that the patient is suffering from financial hardship.  If the practice does routinely offer discounts or waivers of deductibles without properly investigating a patient’s financial wherewithal, the practice runs the risk of violating its payor contracts, being accused of committing insurance fraud, and/or paying an illegal kickback to induce patients to come to the practice.  Some payor contracts require the practice to bill the payor the lowest rate that the practice bills any of its patients, a so-called “most favored nation provision.”  Typical Medicare participation agreements are subject to this type of provision.  If the practice waives deductibles or co-pays, then insurers often take the position that the amount being billed by the practice to the insurer ought to be reduced by the amount waived.  In addition, a regulator could conceivably accuse the practice of waiving co-pays and deductibles as a means of inducing patients to seek treatment from the practice in violation of anti-kickback laws.

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The Cost of Inaccurate Medical Records

by admin on July 17, 2013 No comments

0607-for-the-record-1690On July 8, 2013 the United States Attorney’s Office for the Southern District of Florida issued a Press Release with the headline “Supervisor of $63 Million Health Care Fraud Scheme Sentenced in Florida To 10 Years in Prison”. The Defendant, a 51 year old employee of the Healthcare Provider was the director of medical records. The employee was a certified medical records technician and was found to have overseen the alteration, fabrication and forgery of documents that were used to support claims submitted to Medicare and Medicaid. In addition, the employee was found to have directed therapists to fabricate documents and forged signatures on documents. The defective medical records were used to support claims to Medicare and Medicaid in excess of 63 million dollars.

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adminThe Cost of Inaccurate Medical Records