The U.S. Department of Health and Human Services, Office of Inspector General has released its 2016 work plan. Because the Inspector General (OIG) is Medicare’s “top cop,” knowing what they are investigating creates a boon for would-be whistleblowers.
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.
Because the length of the list, this post is in several parts. Future parts will be linked here. Part two. (If you are reading this post on a third party website, visit the MahanyLaw blog and use the search feature to search for “Medicare Fraud 2016.”)
Medicare Fraud, Whistleblowers and Cash 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…Hospital Outlier Payments
Outliers are additional payments that Medicare provides to hospitals for beneficiaries who incur unusually high costs. While these payments are often legit, we have personal knowledge of hospitals who have illegally rigged their cost reports and manipulated records to receive higher payments.
Outpatient and Inpatient Stays under Medicare’s New Two Midnight Rule
Medicare is trying to keep hospital stays short unless there is a medical reason to keep the patient longer. Longer stays also increase the risk of infection. Whenever possible, Medicare wants to see more patients treated on an outpatient basis.
Of course, hospitals make more money when a patient is admitted and spends the night.
Unnecessary hospitalizations have been a long time issue for Medicare and the Inspector General. Whistleblowers have received millions of dollars in awards for reporting hospitals that pay incentives to doctors who admit more patients. The latter situation triggers a second anti-fraud rule, the Anti-Kickback Statute.
Closely related to the Inpatient – Outpatient rules are the rules dealing with provider owned facilities. Many hospitals own other facilities. Medicare wants to insure that patients aren’t being shuffled among facilities simply to generate more billings. Often these facilities also have higher reimbursements than nearby free standing clinics.
Claims for Mechanical Ventilation
Mechanical ventilation is the use of a ventilator or breathing apparatus used to take over breathing for a patient who is unable to breathe on his or her own. Certain dire situations trigger “Medicare Severity Diagnosis Related Group” (MS-DRG) assignments. Hospitals receive much more money in these cases. Medicare wants to know if hospitals are properly following the MS-DRG rules. For example, in order to qualify for the higher severity diagnosis billing, patients must be on a ventilator for at least 96 hours.
The Inspector General claims it has found instances where hospitals were billing for more severe diagnoses even though patients only required a short period of mechanical breathing assistance. We are looking for whistleblowers that are hospital nurses, physicians, respiratory therapists and billing clerks.
Acute Care Hospitals
Acute care hospitals are often referred to as trauma centers. The Inspector General says these facilities will be receiving more scrutiny because of recent “areas at risk for noncompliance.” The OIG is keeping its cards close to the vest on this one. Obviously they are aware of problems and those problems could be ripe for whistleblower claims.
Double Billing of Interns
The Inspector General says some facilities have engaged in “duplicate graduate medical education payments.” From what we can glean from the report, some hospitals double count residents and interns.
Teaching hospitals receive a higher Medicare reimbursement. The added dollars are designed to reflect the higher costs that teaching hospitals have when compared to non teaching hospitals. Once again, the Inspector General says it is aware of hospitals charging too much for their IME costs.
Outpatient Dental Claims
Prior audits have revealed that hospitals sometimes have received “significant overpayments” attributable to noncovered dental services. Most dental services are not eligible for Medicare. There are a few exceptions, however, and some hospitals seem to be exploiting the system by incorrectly coding ineligible services.
Cardiac Catheterizations and Endomyocardial Biopsies
Some hospitals are trying to increase their Medicare billing by unbundling these services. Typically, Medicare rules say that right heart catheterizations are included in endomyocardial biopsies.
It is hard to know how widespread this problem is; however, we are actively investigating one such whistleblower claim in the southwest United States.
Kwashiorkor is a severe form of protein malnutrition affecting children. Commonly associated with famine, it is rarely found in the United States. The OIG says it has found more than one hospital improperly billing for this disease.
Wrongful diagnoses should be relatively easy for medical whistleblowers to detect. Hospitals and clinics often “upcode” or increase the severity of a patient’s diagnosis solely to collect more money from Medicare (and taxpayers).
END PART ONE
If you have inside information about Medicare or Medicaid fraud and are interested in becoming a whistleblower, call us. The inquiry is free, confidential and protected by the attorney – client privilege… even if you decide to do nothing.
Calling a toll free tip line may get you a $1000 reward but little else. There is nothing wrong with healthcare 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. Don’t contact us from a work phone, computer or email address, however.
It’s that simple. 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.
Whistleblowers are the new American heroes. They save lives, save tax dollars and help put patients first. 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.