In a small but mighty settlement against an experienced Connecticut physician, the Department of Justice recently exposed significant fraud and upcoding schemes within a Ridgefield office specializing in geriatric care. The physician, who has been practicing medicine for over 40 years, is alleged to have instructed his staff and billing professionals to engage in the illegal practice of submitting inflated and exaggerated bills to Medicare and Medicaid – obviously in flagrant violation of the False Claims Act.
The violations, which allegedly occurred between January 2008 and March 2014, resulted in a settlement amount of $218,633. While certainly not the largest settlement seen this year, the case stands as an important reminder to those in the healthcare industry to be mindful of suspicious billing practices and less-than-honest invoices to federally-funded healthcare agencies.
Details of the alleged billing violations
According to the details of the press release published by the Department of Justice, the Connecticut physician was engaging in illegal upcoding of skilled nursing facility services that either were not eligible for reimbursement, did not actually occur, or did not occur to the extent reflected by the invoice.
Skilled nursing facility services are covered by Medicare only in limited circumstances and when considered necessary by the patient’s treating physician. Understandably, programs like Medicare and Medicaid must be discerning when reimbursing for this costly, round-the-clock care, making skilled nursing a common area for illegal upcoding and fraudulent billing within the healthcare industry.
According to the Department of Health and Human Services, over $1 billion is lost each year as a result of inappropriate billing practices within the skilled nursing facility realm.[1. Department of Health and Human Services, Office of Inspector General, “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009.” November, 2012. https://oig.hhs.gov/oei/reports/oei-02-09-00200.pdf laims-act] According to a 2009 study, the following issues are most common within the skilled nursing billing process:
▪ Billing for high or ultrahigh levels of therapy when the patient did not receive such intensive treatment
▪ Billing for therapy that a patient did not need or was not conducive to his or her care plan
▪ Billing for services and therapies contrary to the physician’s orders
▪ Misreporting costs of daily living
▪ Billing for more costly feeding services
▪ Exaggerating costs to treat skin conditions
In today’s case, U.S. Attorney for the District of Connecticut remarked, “Healthcare providers that overcharge Medicare drain critical funds from the Medicare program and increase healthcare costs….The U.S. Attorney’s office is committed to vigorously pursuing physicians and other health care providers who submit fraudulent claims to federal healthcare programs. Providers who submit false claims to the government face serious monetary and administrative sanctions.” [2. Department of Justice Press Release, “Ridgefield Doctor Pays $218,633 to Settle Allegations under the False Claims Act.” June 18, 2015. http://www.justice.gov/usao-ct/pr/ridgefield-doctor-pays-218633-settle-allegations-under-false-claims-act]
Contact Berger Montague for further assistance in healthcare fraud matters
Healthcare fraud is one of the most prevalent forms of financial misconduct facing the United States today. If you are aware of suspicious billing practices, please do not hesitate to contact Berger Montague today.