Illegal billing practices are one of the most common components of a False Claims Act lawsuit. Oftentimes, healthcare facilities engage in years’ worth of fraudulent billing practices before a courageous whistleblower comes forward with allegations of misconduct. At that time, the federal government may opt to intervene in the matter and the perpetrators may face up to triple damages, as well as fine of up to $11,000 per incident of fraud.
In today’s case, we explore a recent $20 million settlement between the Medical Center of Central Georgia and the U.S. government. According to the allegations, the MCCG was illegally upcoding services provided to patients, as well as ordering medically unnecessary procedures to pad profits.
The case arose as a result of an investigation involving the Department of Health and Human Services, along with the U.S. Attorney’s Office for the Northern District of Georgia.
Details of the allegations against MCGG
MCGG is currently the second largest hospital in the state of Georgia. According to the allegations, the hospital had illegally structured its hospital admission policies so as to increase the number of Medicare admissions when less-expensive outpatient or observation services would have met the patients’ needs.
More specifically, the hospital is alleged to have admitted Medicare enrollees for inpatient care who did not meet the specific criteria set forth by the Medicare guidelines for the provision of such costly medical services. Currently, inpatient medical care is covered by Medicare only when:
-A treating or attending physician has deemed the patient’s condition serious enough to admit the patient for at least two nights (Known as the 2-midnight rule).
-The patient’s need for medical care is considered medically necessary, and an observation period is likely insufficient to treat the patient’s ongoing condition.
Naturally, Medicare reimbursements for inpatient hospital stays are much greater than a one-night observation stay or outpatient services. Accordingly, facilities engaging in medically unnecessary inpatient admissions could face severe False Claims Act liability, as in the case against MCCG.
Government responds to allegations
According to the U.S. Attorney’s Office for the Northern District of Georgia, “Overcharging the government for medical services wastes our country’s limited healthcare resources….When a provider inflates its billings, we will aggressively seek to recover the overcharges under the False Claims Act.”
The Department of Health and Human Services similarly commented, stating, “Unnecessarily admitting patients who could have been treated in an outpatient or observation setting is not only a waste of taxpayer dollars, but a fundamental breach of trust….Medicare beneficiaries must feel secure and know that the care selected for them is in their best interest, and not merely what will generate the most revenue for the facility.”
Contact Berger & Montague, P.C. today
If you are aware of healthcare fraud or illegal billing practices in your place of employment, we encourage you to contact Berger & Montague, P.C. right away to speak with an experienced False Claims Act attorney.