Medicare Billing FraudMedicare covers about 56 million people, both those 65 and older as well as disabled people. However, this major public program is plagued with fraud with offenders claiming tens of billions in Medicare health care reimbursement to which they are not entitled. Medical billing and coding companies play a key role in helping healthcare providers avoid questionable billing practices that could amount to fraud, including Medicare billing fraud. Now, a private company is offering rewards for information on Medicare billing fraud.

In a recent press release, the Corporate Whistleblower Center called upon medical doctors, healthcare managers or pharmaceutical/medical device company sales representatives to contact them about significant rewards if they can prove “a healthcare company has been or is intentionally up-coding Medicare bills or fraudulently billing to the highest possible Medicare reimbursement rates, as opposed to billing at the correct levels based on the actual service that was provided”.

The press release mentions, as an example, a case involving two cardiac monitoring companies that agreed to pay $13,450,000 to settle Department of Justice allegations that they violated the False Claims Act by billing Medicare for higher and more expensive levels of cardiac monitoring services than requested by the ordering physicians. From 2011 through 2016, the companies allegedly sold a remote arrhythmia monitoring system that could perform three separate types of cardiac monitoring services-holter, event, and telemetry. However, when they enrolled a patient in the cardiac monitoring system, physicians found that they could only enroll for the service which provided the highest rate of reimbursement provided by the patient’s insurance, which led the ordering physician to an expensive level of service.

Houston Chronicle recently reported on case of fraudulent Medicaid and Medicare billing was a “brazen scheme” involving more than $17 million. From 2009 to 2016, the owner of five Houston home health care clinics submitted claims to Medicare and Medicaid for patients who did not need or receive the services.

Corporate Whistleblower Center says it will reward providers who can provide evidence that Medicare was overbilled for services never rendered or at the highest reimbursement codes instead of the correct codes for services rendered.

Here are some common examples of Medicare fraud:

  • Billing for unnecessary services: This involves billing Medicare for services or medical supplies that were not medically necessary.
  • “Phantom billing”: This refers to the practice of billing the payer for tests or services that were not performed.
  • Overbilling for services: Charging twice for a service or procedure that was only performed once amounts to fraud.
  • Up-coding: This occurs when the healthcare organization bills Medicare at a higher rate than is called for by the services rendered by altering the diagnostic or treatment codes.
  • Submitting falsified patient records: Patients’ medical records are altered to cover up care not rendered and receive unjustifiable reimbursement from Medicare. In the recent case of Medicare fraud in Houston, the owner of the clinics allegedly paid physicians to create false documentation indicating the patients had ailments that qualified them for home health services.
  • Unbundling services: Medicare rules stipulate that certain types of services must be billed at reduced, “bundled” rates. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. Doing this deliberately to receive a higher payment is fraudulent.
  • Making prohibited referrals: Making prohibited referrals for certain designated health services is another form of Medicare fraud. Under the Stark Law, physicians are banned from making certain referrals to companies with which they have a financial relationship.
  • Offering or accepting illegal kickbacks: Physicians, pharmaceutical companies and others are prohibited from making or accepting payments for referring, recommending, or arranging for the purchase of items paid for by federally-funded programs.

Medicare Billing FraudIn the guidelines on the Prevention, Detection, and Reporting of Medicare Fraud, the Centers for Disease Control and Prevention states, “Committing Medicare fraud exposes individuals or entities to potential criminal and civil liability, and may lead to imprisonment, fines, and penalties. Criminal and civil penalties for Medicare fraud reflect the serious harms associated with health care fraud and the need for aggressive and appropriate intervention. Providers and health care organizations involved in health care fraud risk exclusion from participating in all Federal health care programs and risk losing their professional licenses”.

Most physicians strive to deliver high quality care and are honest, earning respect and trust from both payers and patients. Billing and reimbursement are integral parts of the practice of medicine and there’s nothing more important than accuracy when it comes to medical billing. Nevertheless, it has been found that many investigations, prosecutions, settlements and sentences are the result of errors, omissions, misunderstanding, and lack of knowledge of the rules and regulations governing the filing of health-care claims. Partnering with an experienced medical billing and coding company can help healthcare providers ensure full compliance with the rules and regulations and avoid inadvertent fraud. Their teams will check that all codes are accounted for, that no additional codes are reported, and all the necessary aspects of billing are complete when submitting claims.

While a responsible medical billing company can help practitioners avoid unintentional fraud, all physicians need to be mindful about their actions and steer clear of deliberate fraud, waste, and abuse. They should be aware about the important federal fraud and abuse laws such as the False Claims Act (FCA), Anti-Kickback Statute and Physician Self-Referral Law (Stark Law). Under these rules, healthcare providers found guilty of Medicare fraud, patient abuse, and felony financial misconduct, can be excluded from participation in all federal health programs.