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Did hospital execs & lab owners commit $1B in health care fraud?

The United States Department of Justice (DOJ) recently accused a group of 10 individuals of partaking in a health care fraud scheme that cost the government over $1 billion. The accused include hospital executives and diagnostic lab owners as well as billers.

According to the government, the group perpetrated a health care fraud scheme by taking over rural hospitals and using these small hospitals to bill private insurance companies for urine and blood tests. The government argues the billers would claim the testing was completed within the rural hospital when in actuality it was completed using outside labs. this, the prosecution claims, allowed the group to use rural hospitals as a type of shell company to illegally bill insurance providers. The government pursued two claims against this practice. First, that the group was using illegal billing practices to inflate reimbursement rates. Second, that many of the tests were not medically necessary.

CMS provides guidance on eligible telehealth services for 2021

The United States Centers for Medicare and Medicaid Services (CMS) recently released a publication outlining telehealth services that will be eligible for coverage in 2021. The agency’s list includes 39 telehealth-eligible services, such as:

  • Preventive Care and Screening appointments for depression as well as child and adolescent Major Depressive Disorder suicide risk assessments
  • Functional Status Assessments for hip and knee replacement procedures
  • Primary care prevention intervention services provided by primary care physicians and dentists
  • Childhood immunization status appointments
  • Breast, cervical and colorectal cancer screening appointments
  • Controlling high blood pressure appointments

The list, the Medicare Telehealth Service list, is subject to change.

Doctor loses license after suffering medical emergency

A pain management physician lost consciousness while on duty. Medical staff were able to promptly intervene and successfully treat the doctor. Shortly after the incident, the Texas Medical Board suspended his medical license. The Board's action triggers two important questions:

Question #1: Is this legal?

The Texas Medical Board has the authority to determine whether or not a physician can practice medicine in the state. In order to keep their medical license, physicians in the state of Texas must follow the Board's rules. Those who violate these rules can have their license to practice medicine suspended.

TX couple faces seven health care fraud charges

Government authorities recently accused a former surgeon turned business owner of running a criminal enterprise in Texas. The physician transitioned from practicing medicine within the operating room to serving as the owner of an orthopedic and spinal disorder clinic in the Fort Worth area. During his time as a business owner, government authorities state he committed multiple acts of health care fraud.

How did the business owner commit health care fraud? Investigators claim to have evidence that from 2014 through 2017 the couple filed over 100,000 false claims with federal health care programs for physical therapy and pain management services that were not medically necessary. Ultimately, the government states the couple’s claims led to the fraudulent payment of over $5 million.

Novartis to pay millions to settle health care fraud claims

The government continues its crackdown on the use of bribes in the medical field. Although it is noble to better ensure physicians are motivated by patient need and not financial gain, the distinction between what is legal and what is not can be difficult to determine. A recent case provides an example of this distinction and the extreme penalties that can come with a violation.

Hospital system agrees to $16M settlement for decade old claim

The Department of Justice (DOJ) recently announced a southern hospital system, Piedmont Healthcare, Inc., had agreed to pay $16 million to settle allegations of wrongdoing. Both parties intend the settlement to resolve two separate legal claims.

How did the case begin?

The case is a result of a qui tam action. The False Claims Act (FCA) includes a provision that allows citizens to move forward with a qui tam, or whistleblower, action. In this instance, a private citizen brought the case forward and will receive a portion of the settlement. The government has stated the individual that brought the claim forward in this case will get almost $3 million of the government's recovery.

Hospital fights allegations of false claims

Hospitals often face allegations of wrongdoing. In some cases, the allegations can be severe and can lead to serious financial penalties as well as criminal liability for individuals that are involved. In one recent example, former employees of a hospital from Tennessee claimed the hospital filed false documents to get money from the government.

Hospitals take on HHS over price disclosure rule

The United States Department of Health and Human Services (HHS) issued a rule in November that requires hospitals to disclose the rates they negotiate with insurance providers. The rule requires hospitals begin to provide this information to the public in 2021. In response to the rule, the American Hospital Association, Association of American Medical colleges, Children's Hospital Association and Federation of American Hospitals filed a lawsuit against the HHS, stating the agency did not have the authority to require hospitals to make the disclosure.

Lawmakers state the required disclosure will result in increased information for the public, allowing patients to make better, more informed choices about their care. Hospitals counter, stating the rule results in an unreasonable burden. They also voice concerns about the timing of implementation of the rule, stating the impact of the coronavirus pandemic has already depleted their resources.

Doctor gets four years in prison for health care fraud

The United States Attorney’s Office recently announced a physician has pled guilty to criminal health care fraud charges. The charges are the result of a health care fraud investigation that led to over 15 criminal charges for four medical professionals.

Texas BON announces changes to NLC agreement

The Texas Board of Nursing (BON), a part of the Nurse Licensure Compact (NLC) for almost 20 years, recently announced proposed changes to the NLC agreement. Participation in the NLC allows for nurses to have mobility across state boarders. This increases a patient’s access to care while also increasing the nurse’s ability to practice in their chosen profession.

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