Fraudulent medical billing is a major and costly problem for government-sponsored healthcare programs such as Medicare and Medicaid. Most of the time healthcare frauds go undetected, costing taxpayers billions of dollars each year.
The official website of the United States Attorney’s Office reports that Baltimore, Maryland B Medical billing company Engage Medical, Inc. and three medical practices that were its clients have agreed to pay a total of $3,340,979 to resolve claims that Engage Medical overbilled for nuclear stress tests conducted between July 2007 and March 2011. Nuclear stress tests are designed to assess cardiac function. Prosecutors claim that physicians and practices hired Engage to help process billings, and the company routinely billed Medicare twice for the same tests.
Engage Medical marketed these tests to general practitioners, persuading them that instead of referring the patients to cardiologists for these tests, Engage could arrange to have the testing service performed in the general practitioners’ offices and bill for the tests, all of which would increase the general practitioners’ incomes.
Engage Medical systematically billed for each service twice, using a CPT code modifier which is to be used when the service is repeated by the same physician or when a distinct service is performed on the same day. In fact, none of the tests were repeated and none of the tests was a distinct procedural service.
The settlement over the issue was the result of an investigation by the United States Attorney’s Office for the District of Maryland, with assistance from the Office of the Inspector General for the Department of Health and Human Services.
These fraudulent medical bills are detrimental to the entire healthcare system and contribute to higher healthcare costs and increased costs for coverage.
What Can Be Done?
If the carrier’s Fraud and Abuse Unit suspects any fraud case, they must refer the cases to the Office of the Inspector General for consideration and initiation of criminal, civil monetary penalty, and/or administrative sanction actions.
At the same time, providers have the responsibility to stay current with Medicare rules and regulations. They should also ensure that the administrative personnel understand Medicare guidelines as they pertain to reports of services provided. If accused of fraudulent billing, physicians may end up facing heavy fines, the loss of their practice, criminal indictments, public embarrassment, and possibly a jail sentence.