This is part two of a multi-part post outlining emerging trends in Medicare fraud. This series tracks the current 2016 work plan of the U.S. Department of Health and Human Services, Office of Inspector General (OIG). The Inspector General serves as Medicare’s top cop. Anyone interested in helping stop healthcare fraud or earning a large whistleblower award should read this series. Other parts of this story can be found here. Part One. (If you are reading this post on a third party website without working links, visit the MahanyLaw blog and use the search feature to search for “Medicare Fraud 2016.”)
We caution readers that healthcare fraud is everywhere. Simply because a given topic isn’t high on the OIG’s radar doesn’t mean they aren’t interested.
In our experience, prosecutors are interested in Medicare fraud wherever it may be located and however it may be occurring. We already know that some geographic areas are worse than others (Miami, Detroit, Houston, Chicago, Tampa, Los Angeles, New Orleans, Brooklyn, and Dallas). We also know that some types of health services have a higher rate of fraud (home health care, EMS, radiology, pain clinics and durable medical equipment). This post looks at what the OIG will be looking for this year. We encourage healthcare workers, however, to come forward with any evidence of fraud.
Medicare Fraud and Cash Whistleblower Awards
Before identifying the Inspector General’s specific concerns, some discussion is necessary on the False Claims Act. This law allows whistleblowers who report fraud to collect large cash awards. Typically, the awards are between 15% and 30% from the wrongdoer.
Passed during the U.S. Civil War, the False Claims Act requires inside information about fraud involving a government program or funds. Each year the Justice Department hands out hundreds of millions of dollars in awards. (Our clients have received over $100 million.)
The False Claims Act also contains powerful anti-retaliation provisions.
Whistleblowers and… Bone Marrow / Stem Cell Transplants
Bone marrow and stem cell transplants are a relatively new addition to the OIG’s priority list. Regulators claim that prior audits have uncovered hospitals illegally billing for these services. These transplants are covered only when certain diagnoses are present. In addition, when these services are covered, all necessary steps are included. Some hospitals may try to unbundle the services and charge separately hoping to get more money.
Hospital Wage Data Used to Calculate Medicare Rates
The OIG says hundreds of millions of dollars in wage data has been improperly reported by hospitals. Medicare looks at a hospital’s pay rates, determines if they are reasonable and then determines reimbursement rates. Some hospitals manipulate the data hoping to get higher reimbursement.
The ideal whistleblower in these cases is someone within hospital management or accounting.
Intensity Modulated Radiation Therapy
Intensity-modulated radiation therapy (IMRT) is an advanced mode of high-precision radiotherapy that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. The OIG says that prior audits have uncovered billing abuses with these highly specialized – and costly – services.
Medical Device Credits (Replaced Medical Devices)
This item is brand new to the OIG’s annual work plans. From what we understand, surgically implanted devices often must be replaced. Sometimes they are recalled or are defective. Apparently, some hospitals are receiving refunds from the manufacturer but not passing along those savings. If a hospital is reimbursed by a manufacturer, it can’t then also bill Medicare.
Inpatient Rehabilitation Services
Many patients are discharged from hospitals into skilled nursing and rehabilitation facilities. Medicare paid $7 billion for these services in 2011 and they say the reimbursement amounts have been growing rapidly since. To qualify for reimbursement, patients must receive 3 hours of therapy per day. The OIG believes that some patient stays do not qualify and that other lower cost alternatives are often available.
We are looking for whistleblowers that work in these facilities. In our experience, this type abuse happens frequently.
Long Term Care Hospitals
Like skilled nursing facilities and Inpatient Rehabilitation Services, LTHCs are a huge drain on Medicare. Sometimes the level of care being billed is not the same as the care being received by patients. Worse, we have received whistleblower reports of deplorable conditions and understaffing. All are potential Medicare violations.
National Background Check Program
Four years ago the feds began requiring employees of nursing homes and other long term care facilities to undergo background checks. The OIG now wants to see if these facilities are complying. If a facility isn’t complying but still receives Medicare money, there could be significant penalties involved. Those penalties could add up to be nice whistleblower awards.
Skilled Nursing Facility Therapy Payments
This is new to the OIG’s list but old news in the healthcare industry. Medicare is paying more for therapy than the actual cost of that therapy. We have seen multiple cases where SNF’s engage in upcoding and improperly billing at the highest possible rates. Sometimes we even see treatments that must be performed by a physician being performed by unlicensed technicians yet still billed at physician rates.
Most whistleblower cases involve overbilling. When a nursing facility uses unqualified personnel to perform essential services, however, the fraud becomes much more than money. It becomes a patient safety issue.
Earlier this year, the Justice Department concluded a record number of Medicare fraud and whistleblower claims against hospice care providers. One resulted in an award of over $300 million. (That case is under appeal.) The apparent rampant abuse within the hospice care community has gained the attention of regulators.
Fraud occurs when patients are improperly placed into hospice care. Generally, patients should be within the last months of their life. We have seen, however, hospice providers paying bribes and kickbacks to nursing homes and finding doctors to falsely certify a patient’s eligibility for care.
Home Health Care
Home health services include part-time or intermittent skilled nursing care, as well as other skilled care services, such as physical, occupational, and speech therapy; medical social work, and home health aide services. The principal behind home health care is sound. It is often far less expensive to keep people in their own homes for as long as possible. It is also better for the patient. Most patients would rather be treated in familiar surroundings than in a nursing home. Unfortunately, the home healthcare industry is rife with fraud.
Medicare reports that one in four home health agencies has engaged in questionable billing. In recent years, that equates to over $1 billion in fraud.
The whistleblower need in home health care is great. Most home care agencies are quite small. The whistleblower awards are therefore smaller but there are plenty more opportunities. In our experience, the risk to patients is also much higher. We are working a case right now where a woman legitimately needs twice weekly in home therapy. According to her Medicare statement of benefits she is receiving that care but she claims the therapists are untrained and stay for just a few minutes. Taxpayers pay for worthless services, an elderly woman suffers and the operator of the agency rakes in money.
END PART TWO
Have inside information about Medicare or Medicaid fraud or interested in becoming a whistleblower? Contact us right away. Whistleblower awards are generally only paid to the first people filing a claim. Waiting can hurt your chances of collecting an award.
Worried about affording a lawyer? We never charge for our services unless you recover money. That means the inquiry is free. It is also confidential and protected by the attorney – client privilege… even if you never hire us.
Calling a government Medicare fraud hotline may get you a $1000 reward but little else. There is nothing wrong with fraud hotlines, however most are overworked and understaffed. The only way to qualify for a large award is through the federal False Claims Act. That law pays percentage awards and contains important whistleblower anti-retaliation and protection provisions.
Need more reasons? Under the False Claims Act, whistleblowers can have their identity shielded. Finally, because whistleblower complaints under the Act have to be investigated, they are the best way to end the fraud.
For more information, contact attorney Brian Mahany at or by direct dial at (414) 704-6731. Want to remain anonymous at first? That is okay too. Just email us and provide as much information as you feel comfortable.
Taking the first step is easy. Pick up the phone or email us. We will evaluate your information, explain the pros and cons, investigate and file all necessary court actions and work tirelessly to get you the maximum possible award. Medicare fraud costs taxpayers’ tens of billions of dollars annually. Sometimes when Medicare fraud involves unnecessary treatment it can mean needless human suffering and even death.
We believe that whistleblowers are the new American heroes. They save lives, save tax dollars and restore integrity to healthcare. Our goal as whistleblower lawyers is to help you… help you stop the fraud, protect patients, earn the largest possible award and protect you should you suffer retaliation. To date our client – whistleblowers have received over $100 million in awards.
MahanyLaw – America’s Whistleblower Lawyers