Healthcare fraud occurs when the government makes an accusation that someone filed false healthcare claims for financial gain. The government can accuse medical professionals throughout the healthcare field of a violation. Examples include:
The False Claims Act (FCA) makes it illegal to use false or fraudulent claims to seek payment from government sources, like Medicare and Medicaid. This law is complex. Court cases have questioned the best way to apply the FCA to establish a violation. These cases often require the plaintiff establish four elements: "(1) a false statement or fraudulent course of conduct, (2) made with scienter, (3) that was material, causing (4) the government to pay out or forfeit moneys due." The outcome of these cases often hinges on the scienter and materiality elements.
Audit activity by government regulators and private payers has been on the rise. These investigations ramped up throughout 2017 and accelerated through 2018. The dramatic increase in audits is likely connected to the price cuts implemented with the new Medicare Part B.
The United States Department of Health and Human Service’s (HHS) Office of Inspector General (OIG) recently released a report that states most Medicare claims from durable medical equipment supplies for payment for replacement positive airway pressure (PAP) device supplies were not in compliance with Medicare requirements.
After over ten years of investigating and searching, the United States Department of Health and Human Services has recaptured and charged a man with healthcare fraud. In response to the initial charges made ten years ago, the accused fled. He left the country and, until recently, was in Haiti.
The New York state and federal government recently conducted an investigation into the operations of a local skilled nursing provider. The center under investigation provides long-term care services to patients in the community. These services can include adult day health care and skilled nursing visits to patients’ homes.
The Department of Justice (DOJ) accused a large drug company of paying kickbacks to medical professionals to encourage the physicians and nurse practitioners to prescribe their medications. The DOJ’s has accused the company of using kickbacks to encourage the prescription of a powerful, opioid pain medication approved by the Food and Drug Administration for cancer patients for the treatment of persistent pain for non-covered uses.
The New York State Attorney General recently sentenced a pharmacist for his role in a healthcare fraud scheme. The government accused the medical professional of filing over 1.5 million in fraudulent payments with the New York State Medicaid program.
Medical professionals often rely on payments from Medicare for services provided to patients. The United States Department of Health and Human Service’s Centers for Medicare and Medicaid Services administers this program and requires medical professionals meet certain criteria to receive payment. In some situations, the government can choose to exclude a professional’s ability to request payments.
A data analytics firm has accused a healthcare provider of False Claims Act violations. The group states the provider illegally received payment for over $188 million in Medicare claims. If the suit is successful, the firm would receive a portion of the winnings.