It all started back in 2018. At that time, a whistleblower stepped forward with evidence that a healthcare provider in the Houston area was billing Medicare for services that were never provided or were dangerous to the client. Upon review, the government decided the whistleblower’s claims had merit and chose to join the case. The government investigated and claims to have gathered evidence to establish various violations, including:
- Physician did not provide services. The government states the facility filed claims for services never provided to patients. They support this allegation with evidence the billing physicians were not in the country at the time of the procedure.
- Services were medically unnecessary. The prosecution also argues the medical records did not support the need for billed medical services.
- Unauthorized practice of medicine. The government states the physician running the long-term care hospital allowed unlicensed students to perform medical procedures.
- Fraudulent billing. The group would then file a claim for the procedures noted above, stating that the physician performed the medical services.
When faced with the evidence, the group chose to settle the allegations and paid the government one of the largest settlements the Houston area has ever seen to resolve the matter — over $20 million.
Although historically high, large settlements and penalties for these types of allegations are not uncommon. As such, those who practice in this area can learn the following from this case to help mitigate their own risk of similar allegations.
#1: The importance of regular internal audits cannot be understated.
It is important to have a compliance program in place and to check in regularly to make sure the organization is following these expectations.
#2: It is never too late for change.
Those who do not yet have a compliance program can put one in place. It is likely wise to include an internal audit to look for any failure to comply with applicable regulations and address those issues while moving forward with a compliance program.
#3: Patience and perseverance are important.
If accused of these types of violations, the cases often take years to move forward. Know that the issue is unlikely to resolve quickly and prepare for the long-haul. The good news is that you do not need to go through this alone. The law allows you the right to legal counsel to protect your interests and guide you through the process.
Attorney John Rivas is responsible for this communication.