US recovered $3.3B in fraudulent healthcare claims in 2016
- During fiscal year 2016, the federal government reclaimed more than $3.3 billion in fraudulent healthcare claims — yielding a return on investment of $5 for every dollar expended, according to a new report by the HHS Office of Inspector General.
- The Medicare Fraud Strike Force also imprisoned 290 defendants sentenced during the year, with jail times averaging more than 48 months.
- In the area of home health, Medicare payments have dropped by about $1 billion annually since CMS implemented a cap on total outlier payments of no more than 10% of payments an individual provider may receive in a year.
The funds were reclaimed under the Health Care Fraud and Abuse Control Program, a joint effort of HHS and the Department of Justice. Since its launch in 1997, HCFAC has returned about $31 billion to the Medicare Trust Funds, the report notes.
Among noteworthy cases in fiscal 2016:
- The owner/operator of HIV/AIDS clinics was ordered to pay $12.2 million and sentenced to five years in prison for a kickback scheme that paid patients to come to the clinic, lie to doctors to justify billings and billed Medicare for medicines that were medically unnecessary, incorrect or never administered.
- South Carolina-based Tuomey Healthcare System paid $72.4 million for billing Medicare for services referred by doctors under an illegal financial arrangement.
- Tenet Healthcare and four of its hospitals agreed to pay roughly $390 million for Federal Claims Act violations involving kickbacks for patient referrals.
- Prost Data, a drug testing lab in Nashville, paid $9.4 million to settle charges it help finance EHR systems for client medical practices in exchange for patient referrals.
Meanwhile, the University of Pennsylvania Health System reached a settlement with the U.S. government for the voluntary disclosure of improper Medicare billings at one of its hospitals, the Philadelphia Business Journal reported. Under the agreement, Penn Health will pay $845,000 for two interventional cardiologists who billed Medicare for stent procedures done at Pennsylvania Hospital in Philadelphia between 2008 and 2012. A government investigation determined the stents were not medically necessary.
In 2016, the federal government championed its work on cracking down on healthcare fraud. It sent a message to the industry that more review and compliance is needed to help trim wasteful spending. Last year, after 301 medical professionals were charged with alleged participation in healthcare fraud schemes, Venson Wallin, consulting managing director at accounting firm BDO, shared with Healthcare Dive some tips to avoid healthcare fraud: Measure and monitor, review your compliance program and evaluate your partners.
- HHS Office of Inspector General The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016
- Philadelphia Business Journal $845K settlement: Penn Health System resolves improper Medicare billing claim