Scripps Health, a health care system based in San Diego, has agreed to settle federal False Claims Act allegations for $1.5 million. The Department of Justice accused the system of allowing unauthorized physical therapists to bill Medicare and TRICARE.
As you may know, these two federal health insurance programs limit billing privileges to a list of authorized providers who are enrolled in the system. When services are provided by non-enrolled providers, those services must be directly supervised by an enrolled physician.
The purpose of these limitations, explained the acting assistant attorney general for the Justice Department's Civil Division, is to protect patients from unqualified or unscrupulous health care providers. Requiring enrollment before direct billing will be allowed gives the government a chance to pre-screen doctors and medical professionals.
Unfortunately, Scripps Health allegedly violated the rules. According to the DOJ, it allowed physical therapists who were neither enrolled nor directly supervised by an enrollee to bill for their services.
The mere fact that a certain medical provider was not enrolled in Medicare or TRICARE does not itself imply wrongdoing. It merely means that the government was deprived of its pre-screening opportunity.
That said, the government has no intention of examining each billing to determine whether the services provided were medically appropriate and the provider was legitimate. Instead, It intends to rely on the pre-screening opportunity and to punish providers who fail to comply with the programs' internal billing rules.
"Holding providers accountable protects patients and tax-payer funded health care programs," said the FBI's special agent in charge of the San Diego Field Office. "The FBI will continue to work jointly with its law enforcement partners, utilizing all tools available, to pursue the repayment of monies to federal health care programs such as Medicare and TRICARE."
A final point: The investigation into Scripps Health's alleged billing violations was kicked off by a whistleblower. After that, the FBI, Defense Criminal Investigative Service, and four other law enforcement agencies became involved.
If your organization is ever under investigation for violating the program rules of a state or federal health care insurer such as Medicare, Medicaid or TRICARE, you should contact a health care attorney right away. The earlier attorneys get involved, the greater the opportunity they have to limit the investigation and protect you from litigation or charges.