The Justice Department announced this week the Medicare Fraud Strike Force is pressing charges against 301 defendants in 36 federal judicial districts across the country for their alleged participation in Medicare fraud cases involving about $900 million in false billings. The DOJ said the "coordinated takedown" is the largest in the task force's history in terms of the number of defendants and loss amount.
The act was big enough that the millennial wünder-newsletter The Skimm picked up the story.
Since January 2009, DOJ’s civil division has recovered a total of more than $29.9 billion through False Claims Act cases. More than $18.3 billion of that amount recovered in cases involving fraud against federal health care programs. HHS Secretary Sylvia Mathews Burwell outlined some of the efforts successes on Twitter:
From 2013-2015, @TheJusticeDept @HHSGov recovered $6.10 for every $1.00 spent on fighting fraud.— Sylvia Burwell (@SecBurwell) June 22, 2016
Quick look into two states
The biggest case in the takedown the DOJ cited as an example included five individuals in the Eastern District of New York who were charged for being involved in more than $86 million in physical and occupational therapy claims to Medicare and Medicaid. In this case, the defendants allegedly controlled a network of Brooklyn clinics by paying bribes and kickbacks.
However, more than a third of the defendants - 115 - are located in Florida where healthcare fraud has been plaguing residents for years, particularly in the in the Southern District in which "defendants were charged with offenses relating to their participation in various fraud schemes involving approximately $220 million in false billings for home healthcare, mental health services and pharmacy fraud," according to the DOJ press release.
The state attorney general's Medicaid Fraud Control Unit (MFCU) obtained more than $460 million in settlements and judgments from January 2011 to August 2014 alone.
Earlier this month, Attorney General Pam Bondi announced the charges of 73 South Florida individuals for allegedly participating in schemes to defraud Medicare and Medicaid out of at least $262 million as part of the task force's nationwide takedown.
What it means
Clearly, the government is setting a tone they are going after more healthcare fraud, Venson Wallin, consulting managing director at accounting firm BDO, told Healthcare Dive.
He noted once the ACA was implemented, provisions were made to focus on reducing healthcare fraud as a means to reduce healthcare costs and inefficiencies of the Medicare program. “It’s not an endless supply of money,” he notes. In fact, the Board of Trustees for Medicare released its annual report emphasizing just that.
The report estimated a depletion date of Medicare’s hospital insurance fund in 2028, two years up from its previous report. This is the fund that serves Medicare Part A, helps cover hospital, home health services following hospital stays, skilled nursing facilities, and hospice care for the elderly and disabled.
With the population aging and more Medicare coming into play, there’s more opportunity for those that tend to take advantage of the system whether it be billing for more complicated procedures than were actually performed or operations that were never performed at all.
3 tips for the 'tone of the top' to help combat fraud
While there are clearly bad actors in the stage of Medicare fraud, Wallin notes the industry’s push toward value can create confusing billing processes, which can lead to inadvertent fraudulent claims. When establishing quality metrics, administrators need to understand how decisions may impact overall compliance programs. One question to ask could be, “Are you directly or indirectly incentivizing individuals to stretch the truth to meet certain quality metrics.”
Wallin says the “tone of the top” management need to lead by example, take a hardline stance, and make clear to everyone from physicians and support staff that skewed billing is unacceptable and won’t be tolerated.
This is imperative because costs attributed to fraud cases can add up for health providers. Costs ranging paying for services to clean up the billing process to those associated with entering into a corporate integrity agreement with the DOJ are not cheap and avoidable. Wallin noted these agreements can last up to five years and often require hiring an independent review organization to review and test compliance requirements of the agreements.
He shared three tips to avoid the DOJ from knocking on your door:
- Measure and monitor: With the proliferation of health data rising, administrators don’t want to be surprised if the data point to audit records or documentation leading to embarrassing results or banishment from a Medicare program. “You need to know what’s going on in your shop from a data perspective,” Wallin says. There needs to be monitoring and tracking of the billing, claims data. Unfortunately, management is inundated with data and knowing where to focus oversight, which data to include, how often to look at it, and setting up appropriate monitoring and tracking techniques can prove difficult. It still needs to happen to receive initial compliance issues notices and minimize financial risk, Wallin says.
- Review your compliance program: Some compliance programs were established and shelved years ago but with new legislation and data on the horizon, it’s time to dust off and review the programs. Compliance programs require regular stress-testing, Wallin says. Look at claims, metrics and interview employees from physicians to support staff to make sure what in place is actually functioning. The innovation in the industry over data and legislation offer ample opportunities for new types of fraud to develop so such programs need to be regularly tested and modified.
- Evaluate your partners: Look at your contracts and networks (which are getting narrower) to identify partners that perform at the same level of high expectations that you as a provider have. While it may be a difficult conversation at first, education and discussion over quality are paramount to get everyone in the network on the same page.