Medical practitioners seeking to treat Medicare patients are required to abide by the policy manuals and guidelines put out by the federal government. If a practitioner knowingly violates these mandates and intentionally bills Medicare for reimbursement despite the deviation, this could trigger False Claims Act liability.
One of the more common violations of Medicare guidelines emerging today involves the misclassification of a patient as needing costly inpatient services when outpatient treatment would do just fine. Medicare regulations set forth explicit rules for admitting a patient to an extended stay in the hospital, including the following:
▪ A doctor must make an official order stating that the patient is in need of two or more overnight stays in the hospital in order to properly treat the patient’s illness or injury.
▪ Inpatient treatment must be medically necessary.
▪ The hospital must formally admit the patient.
▪ The patient needs the kind of care that can only be provided by a hospital.
▪ The hospital accepts Medicare.
▪ The hospital’s Utilization Review Committee approves the stay.
If any of the above factors are not present at the time of admittance and the hospital seeks reimbursement, it could face a whistleblower lawsuit – as is the case in today’s post.
Details of the case against Baptist Health Medical Center
Located in North Little Rock, Arkansas, Baptist Health Medical Center performs a gamut of surgical procedures, treatments for illness, and other medical procedures each year. According to the allegations, the federal government took exception to 550 claims for reimbursement occurring in 2008 and 2009, all of which involved the alleged misclassification of hospital stays as inpatient when they should have been billed and/or performed as an outpatient service.
More specifically, the hospital is alleged to have internally classified patients as outpatient but subsequently billed the government for more lucrative inpatient stays. In addition, the hospital is alleged to have admitted patients as inpatient without any physician involvement whatsoever – a clear violation of the requirement that a doctor make an official order for each admittance. Lastly, the hospital is alleged to have scheduled outpatient procedures for patients while simultaneously registering the patients as inpatient.
Baptist Health has not admitted any wrongdoing, and highlights the fact that the government’s allegations involve “less than seven-tenths of 1 percent of the claims submitted during the two years.”
Contact Berger Montague today
Medicare billing fraud is an unfortunate reality in the healthcare industry today, costing taxpayers billions of dollars each year. These cases often hinge on the propriety of codes entered on behalf of patients by medical billing specialists, who are often directed by senior management to “upcode” or include codes for services never rendered or for services that bill at a higher rate than the code for the services actually performed.
For honest and truthful healthcare employees with direct knowledge of this sort of misconduct, a whistleblower lawsuit can help not only put a stop to the issue, but can help recover a lucrative and rewarding award – often up to 30 percent of the ultimate settlement. To learn more, contact our office today.