by Author | May 2, 2017 | False Claims Act
New York Non-Profit Serving Developmentally Disabled Children and Adults Settles Whistleblower Complaint
Alleging False Billing at Queens and Brooklyn Day Habilitation Centers (New York City) — A non-profit serving the developmentally disabled in three states falsely billed New York State Medicaid for day habilitation client services for five years even though its own attendance records showed some developmentally disabled clients were not present, according to allegations in separate whistleblower settlements between the provider and New York State and federal governments, Manhattan-based Qui Tam Whistleblower Attorney Timothy J. McInnis of McInnis Law announced. Read More
SBIR Fraud
Medicaid Fraud
Education Fraud
Duty Fraud
by Author | Jan 29, 2017 | False Claims Act
The HHS OIG issued its work plan for 2017. This is significant to False Claims Act attorneys, relators and litigants because healthcare fraud continues to make up the largest share of FCA recoveries. The Office of Inspector General (OIG) is responsible for maintaining the integrity of the Health and Human Services (HHS) programs, including the Centers for Medicare and Medicaid Services (CMS). It does this by trying to identify, investigate and reduce improper payments and healthcare fraud, waste and abuse.
Here are some of the new and revised issues OIG will be focusing on in 2017:
Medicare Parts A and B
- Hyperbaric Oxygen Therapy Services – Provider Reimbursement in Compliance with Federal Regulations
- Incorrect Medical Assistance Days Claimed by Hospitals
- Inpatient Psychiatric Facility Outlier Payments
- Case Review of Inpatient Rehabilitation Hospital Patients Not Suited for Intensive Therapy
- Nursing Home Complaint Investigation Data Brief
- Skilled Nursing Facilities – Unreported Incidents of Potential Abuse and Neglect
- Skilled Nursing Facility Reimbursement
- Skilled Nursing Facility Adverse Event Screening Tool
- Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement, A Portfolio
- Review of Hospices Compliance with Medicare Requirements
- Hospice Home Care — Frequency of Nurse On-site Visits to Assess Quality of Care and Services
- Comparing HHA Survey Documents to Medicare Claims Data
- Part B Services during Non-Part A Nursing Home Stays: Durable Medical Equipment
- Medicare Market Share of Mail-Order Diabetic Testing Strips: April 1–June 30, 2016 –Mandatory Review
- Positive Airway Pressure Device Supplies – Supplier Compliance with Documentation Requirements for Frequency and Medical Necessity
- Intensity-Modulated Radiation Therapy
- National Background Checks for Long-Term-Care Employees – Mandatory Review
- Ambulance Services – Supplier Compliance with Payment Requirements
- Inpatient Rehabilitation Facility Payment System Requirements
- Histocompatibility Laboratories – Supplier Compliance with Payment Requirements
Medicare Parts C and D
- Medicare Part C Payments for Service Dates After Individuals’ Dates of Death
- Extent of Denied Care in Medicare Advantage and CMS Oversight
- Medicare Part D Rebates Related to Drugs Dispensed by 340B Pharmacies
- Questionable Billing for Compounded Topical Drugs in Part D
- Medicare Part D Payments for Service Dates After Individuals’ Dates of Death
Medicaid
- States’ MCO Medicaid Drug Claims
- Data Brief on Fraud in Medicaid Personal Care Services
- Delivery System Reform Incentive Payments
- Accountable Care in Medicaid
- Third-Party Liability Payment Collections in Medicaid
- Medicaid Overpayment Reporting and Collections
- Overview of States’ Risk Assignments for Medicaid-only Provider Types
- Health-Care-Related Taxes: Medicaid MCO Compliance with Hold-Harmless Requirement
- Health Care-Acquired Conditions – Medicaid Managed Care Organizations
CMS: Health Insurance Marketplaces
- CMS Oversight and Issuer Compliance in Ensuring Data Integrity for the ACA Risk Adjustment Program
- CMS Monitoring Activities for Consumer Operated and Oriented Plan Loan Program
For more information read https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf
by Author | Jan 29, 2017 | False Claims Act
The U.S. Department of Justice announced False Claims Act Recoveries totaling $4.7 Billion in 2016 from successful False Claims Act cases. Of this overall amount, $2.5 billion came from the health care industry, primarily pharmaceutical companies, medical device equipment & equipment companies, hospitals, nursing homes, laboratories, and physicians. The second largest recoveries came from the financial services industry, with $1.7 billion, mainly involving underwriting and lending fraud in the residential mortgage markets.
According to DOJ, whistleblowers filed 702 qui tam suits under the False Claims Act in fiscal year 2016, and DOJ recovered $2.9 billion from these and earlier filed qui tam lawsuits. As a result, whistleblowers were awarded $519 million for cases that settled or were decided in court during 2016.
For more information read https://www.justice.gov/opa/pr/justice-department-recovers-over-47-billion-false-claims-act-cases-fiscal-year-2016
by Author | Feb 24, 2016 | Customs Fraud, False Claims Act, Qui Tam
On Monday, February 22nd, 2016, the Department of Justice announced that four Pennsylvania-based companies and two individuals had agreed to pay $3 million to settle a False Claims Act Suit involving customs duties. The companies—Ameri-Source International Inc., Ameri-Source Specialty Products Inc., Ameri-Source Holdings Inc., and SMC Machining LLC—and the individuals—Ajay Goel and Thomas Diener – were accused with evading customs duties on imports of small-diameter graphite electrodes from China, which are used as fuel in electric arc and ladle furnaces. The U.S. government alleged that the companies had deliberately misclassified the electrodes as a larger size from December 2009 to March 2012; because larger size electrodes are not subject to antidumping duties, the misclassification allowed the companies to evade the necessary customs duties for smaller size electrodes. The allegations resolved by the settlement were originally brought by whistleblower Graphite Electrode Sales Inc. under the qui tam provisions of the False Claims Act. Graphite Electrode Sales Inc., a competitor of the named defendants, will receive approximately $480,000 as its share of the settlement.
by Author | Feb 17, 2016 | False Claims Act
On February 11, 2016, HHS published the long-awaited final CMS OVERPAYMENT RULE. 42 CFR Parts 401 and 405. The rule requires providers and suppliers receiving Medicare Part A and Part B funds to report and return overpayments by the later of 60 days after the date on which the overpayment was identified; or any corresponding cost report is due, if applicable.
Here are some significant provisions that could affect False Claims Act litigation for reverse false claims based on wrongful retention of Medicare funds due to the failure to report and return overpayments:
- The rule is limited to Medicare and does not include Medicaid.
- The rule covers only “providers” and “suppliers” (Part A and Part B); MAOs, Medicaid MCOs and PDPs (Part C and Part D) were already addressed separately in a rule issued in 2014.
- The look back period would be 6 years (from when the overpayment was received), not 10 years as in the proposed rule from 2012.
- The overpayment would have to be properly reported and refunded within 60 days of when it is “identified.”
- “ Identified” means when a person “has, or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.” (Or 60 days from when cost report reconciliation is filed, if applicable and if later).
- A reasonable amount of time to investigate an overpayment was received and to quantify the amount should not exceed 6 months, except in extraordinary circumstances.
- Overpayment Liability exists even if the overpayments were the result of inadvertence or innocent mistakes or errors; fraud conduct is not required.
- The amount of an overpayment is generally “the difference between the amount that was paid and the amount that should have been paid.” However, for claims tainted by violations of the Anti-Kickback Statute or Stark Law, CMS typically will view the overpayment as the full amount received by the provider.
- Sufficient documentation and medical necessity are longstanding and fundamental prerequisites to Medicare coverage and payment and can be the basis of overpayment liability.
- Providers cannot offset identified overpayments with identified underpayments.
- The rule becomes effective March 12, 2016.
See https://www.gpo.gov/fdsys/pkg/FR-2016-02-12/pdf/2016-02789.pdf
