Talking before the Subcommittee on Health of the House Energy and Commerce Committee Levinson, inspector general of the U.S. Department of Health and Human Services (HHS), said these recommendations were based on OIG’s evaluations, investigations and audits on issues, such as fraudulent activity by health care providers; excessive payments for medical services, equipment, and prescription drugs; and financial conflicts of interests within the institutions charged with protecting the health of the American public.

He emphasized that collaboration and innovation are essential in the fight against fraud. Levinson cited the launch of Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint task force consisting of OIG and Department of Justice senior leadership.

The inspector general identified health care vulnerabilities to fraud and waste and outlined OIG’s program to strengthen the integrity of government-run health care, called the Five-Principle Strategy to Combat Health Care Fraud, Waste, and Abuse.

For the full testimony, go to: http://www.oig.hhs.gov/testimony/docs/2009/06252009_testimony_health_reform.pdf.

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA. http://www.whistleblowerfirm.com/.

The sophisticated scheme involved fake clinics, which in reality were empty storefronts or post office boxes–none providing any actual medical services. The defendants face charges ranging from conspiracy to commit Medicare fraud and money laundering to aggravated identity theft. If convicted, the defendants could get prison time and have to forfeit their profits, according to Reuters.

For the full story, go to: http://www.reuters.com/article/latestCrisis/idUSN23304580.

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.

The settlement was the second time UMDNJ paid the government for the double-billing scheme. The first was in 2005 when the hospital paid $4.9 million to the state of New Jersey to settle criminal charges.

In the end, UMDNJ ended up paying nearly $7 million total for the scheme, but, according to Marcella Auerbach, managing partner at Nolan & Auerbach, the hospital could have avoided the lengthy and costly litigation and saved millions, if it had acted differently.

According to Auerbach, a former federal prosecutor who now exclusively represents whistleblowers in healthcare fraud cases, UMDNJ’s in-house attorney discovered the hospital and its physicians were billing for the same services back in 2001-before any whistle was blown. The lawyer brought the issue to the hospital’s attention, but the management looked the other way, and continued to double-bill for the three years following the warning, he says.

The fact that UMDNJ knew about the double-billing, knew it was illegal, and continued to do it, is what makes the case so interesting. According to Auerbach, the hospital could have saved millions if it ceased double-billing and came clean to the government through a self-disclosure.

“It’s a bet,” Auerbach says. “They are betting on the fact they won’t get caught.”

However, UMDNJ hit one too many times and ended up going bust. The man who busted the hospital is Steven Simring, MD, who will collect $801,000 for his efforts.

Based on the details of the case, Auerbach was not surprised to see a doctor blow the whistle on the hospital. Evidence shows that there were many discussions about the double-billing in which doctors expressed concern. Auerbach says it comes as no surprise that Simring would come forward and blow the whistle rather than risk being prosecuted himself.

Auerbach, who has extensive experience in whistleblower cases, says the gambler’s mind-set is common in whistleblower cases. Rather than play by the rules and fess up, many facilities try to sweep problems under the rug and pretend they never happened. Some even go one step further. Auerbach says many times concerned employees will raise a compliance concern only to be handed a pink slip for their trouble, which raises another legal problem.

“These people are fired for bringing points up,” Auerbach says, “Then they come to us and they have two claims.”

Auerbach says this case can be seen as a message to healthcare leaders. The DOJ is saying take any compliance concerns presented by employees or legal council very seriously and, when appropriate, self-disclose. The alternative is a lengthy, expensive, public whistleblower case.

For the entire article, go to: http://www.healthleadersmedia.com/content/234437/topic/WS_HLM2_FIN/Doublebilling-Settlement-Highlights-Whistleblower-Concerns.html

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.

From 1993 to 2004, UMDNJ’s University Hospital submitted claims to Medicaid for outpatient physician services that were also being billed by doctors working in the hospital’s outpatient centers. By submitting duplicate claims for payment, University Hospital doubled billed the government’s Medicaid program, according to the release.

The case against UMDNJ and University Hospital originated in a qui tam, or whistleblower, complaint filed under the Federal False Claims Act.

For the entire press release, go to: http://news.prnewswire.com/DisplayReleaseContent.aspx?ACCT=104&STORY=/www/story/06-09-2009/0005041208&EDATE.

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.

According to the DOJ press release, the settlement resolves allegations that the St. Paul, Minn.-based hospitals overcharged Medicare from 2002 to 2007 by thousands of dollars each time they performed kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures that often are due to osteoporosis. The procedure can be performed safely as an outpatient surgery, but the government contends that the HealthEast hospitals performed the procedure on an inpatient basis in order to increase their Medicare billings.

The settlement with HealthEast follows the government’s May 2008 settlement with Medtronic Spine LLC, corporate successor to Kyphon Inc. Medtronic Spine paid $75 million to settle allegations that the company defrauded Medicare by counseling hospital providers to perform kyphoplasty procedures as an inpatient procedure.

The qui tam or whistleblower lawsuit against the HealthEast hospitals was brought under the False Claims Act.

To read the full press release, go to: http://www.usdoj.gov/opa/pr/2009/May/09-civ-497.html.

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.

The False Claims Act settlement resolves allegations that Regency submitted claims for reimbursement to Medicare and Medicaid for rehabilitation and skilled nursing services that were not reimbursable because the nursing home residents were not qualified for the services, the services were not medically necessary, or they were not supported by adequate documentation, according to the release.

For the full press release, go to: US DOJ.

For more information about Qui Tam law and Health Care Fraud, contact Nolan and Auerbach, PA.

The new interagency effort, called the Health Care Fraud Prevention and Enforcement Action Team (HEAT), is charged with combating Medicare Fraud. The government will also expand Strike Force team operations to in some high-risk fraud areas to fight Medicare fraud on a targeted local level.

Fraud prevention efforts are also strengthened in President Obama’s proposed Fiscal Year 2010 budget. The President’s budget invests $311 million - a 50 percent increase from 2009 funding - to strengthen program integrity activities within the Medicare and Medicaid programs. Combined, the anti-fraud efforts in the President’s budget could save $2.7 billion over five years by improving oversight and stopping fraud in the Medicare and Medicaid programs, including the Medicare Advantage and Medicare prescription drug programs, according to the announcement.

To read the full release, go to: US DOJ For more information about Qui Tam law and health care fraud, contact Nolan and Auerbach, PA.

The plan’s steps, according to the homecare association, would eliminate most of the Medicare fraud attributed to the home medical equipment sector by attacking the problem at the front of the process rather than relying on the “pay-and-chase” approach to stop fraud.  Included in the recommendations: mandate site inspections for all new home medical equipment providers and require site inspections for all home medical equipment provider renewals.

We applaud this Association for its efforts. Its members and taxpayers would be well served if some of the Plan is adopted by congress.

For more information on the American Association for Homecare’s plan, go to www.aahomecare.org/stopfraud. For a press release on the topic, go to http://news.prnewswire.com/DisplayReleaseContent.aspx?ACCT=104&STORY=/www/story/04-22-2009/0005011280&EDATE. And for more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.

The St. Petersburg Times newspaper described this investigation in a May 6 online article as “one of the largest health care fraud cases in the United States.”

To read the press release, go to: http://www.usdoj.gov/usao/flm/pr/2009/may/20090505_WELLCARE_Tpa_HCFraudDPA.pdf. To read the St. Petersburg Times article, go to: http://www.tampabay.com/news/business/article998325.ece. And for more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.

On April 22, 2009,  New York Medicaid Inspector General James Sheehan testified before the U.S. Senate Committee on Homeland Security and Governmental Affairs Subcommittee on Medicare and Medicaid about waste and fraud.

New York was the most successful state in the nation in Medicaid program integrity in the past year, measured by fraud and abuse recoveries reported to the Centers for Medicare and Medicaid Services (CMS). Still, there are opportunities for significant improvement, especially when it comes to fraud prevention, Sheehan says in the statement.

Sheehan says that for fraud prevention to become reality, there must be a proactive, rather than reactive system-one with oversight, investigative and prosecutive efforts.

One example of how today’s system falls short: the government’s investigations of improper payments, when they involve large organizations and the potential for intentional conduct, tend to fizzle after years of investigation. Eventually, these might result in criminal declination or an indictment, with limited effect on the provider, payment of large amounts of money in a civil settlement, and a corporate integrity agreement to address future conduct. The statement goes on to say: “By the time the settlement occurs, the individuals who were in charge at the time have moved on, and the business models have changed …. [And] the stock goes up.”

The text of his testimony is posted on the OMIG Web site.

http://www.omig.state.ny.us/data/images/stories/press_releases/js_dc_testimony.pdf .

For more information about qui tam law and health care fraud, contact Nolan and Auerbach, PA.