A Hickory physician pleaded guilty today to health care fraud charges for submitting to Medicare and Medicaid over $467,376 in fraudulent reimbursement claims, announced Jill Westmoreland Rose, Acting U.S. Attorney for the Western District of North Carolina. Wayne Vincent Wilson, 54, entered his guilty plea before U.S. Magistrate Judge David S. Cayer.
Healthcare Fraud Enforcement Generates Government Revenue
Healthcare fraud is a serious offense and certainly a crime that the federal government has increasingly focused on. The primary reasoning for the enforcement is that a significant amount of tax dollars are at stake and the government consistently receives a high return on investment related to these investigations. In fact, probably the main reason relates to this high return on investment. Take for instance a recent publication from the Department of Justice and the Department of Health and Human Services:
Attorney General Eric Holder and HHS Secretary Kathleen Sebelius today released the annual Health Care Fraud and Abuse Control (HCFAC) Program report showing that for every dollar spent on health care-related fraud and abuse investigations through this and other programs in the last three years, the government recovered $8.10. This is the highest three-year average return on investment in the 17-year history of the HCFAC Program.
As you can see, the return on investment is significant. Therefore, it is no wonder why the federal government spends a significant amount of time on these issues. This should resonate with many healthcare providers because often many healthcare providers might think that it cannot happen to their practice, or that they are too small for the government to focus on them. Reasoning like this often is what puts practices and organizations in trouble.
What are the Risks?
For healthcare fraud generally, the per count risk is a maximum prison term of 10 years and a $250,000 fine. This means that for each claim that the government deems as fraudulent, it is possible that an individual could be receiving significant jail time as well as significant fines. In addition, beyond the healthcare fraud statute, there is significant liability under the False Claims Act, the Stark Law, and the Anti-Kickback Statute if those laws are implicated.
Perhaps an example from the recent settlement can highlight these issues. In this case, a physician was involved and the physician admitted that he had engaged in a scheme to defraud the government over a period of 7 years. Specifically, the physician admitted to submitting fraudulent claims totaling nearly $500,000 for services that were never provided. According to the documents, the physician padded claims by adding services allegedly because he believed that Medicaid did not reimburse enough for the services being provided. For example, the physician apparently added strep tests, and other tests to the office visits. The interesting part about this case is that it occurred with a single physician. This highlights how serious this can be even for solo practices.
What Fraud is the Government Focusing on?
First, the government does focus upon any types of fraud that involve healthcare dollars. There are numerous schemes out there that involve laboratory kickbacks, home health, upcoding, and numerous other mechanisms that attempt to defraud the government. Nevertheless, there are various areas that the government specifically focuses on. In fact, the government publishes an annual report providing guidance on major areas of enforcement.
The specific areas of enforcement in the 2015 Fiscal Year Work Plan include the following:
- Chiropractor Services – Specifically the government has noted that it is focusing on Part B payments for noncovered services. What this means is that the government believes payments are being made for certain services that are not covered. For example, chiropractic maintenance therapy is not considered to be medically necessary and is therefore not payment. In addition, the government is generally focusing on questionable billing by chiropractic providers. The government noted in the report that it identified a chiropractor with a 93% claim error rate which resulted in almost $700,000 in payments.
- Diagnostic Radiology and Imaging Services – In addition, the government is also focusing on high cost diagnostic radiology tests that are not considered reasonable and necessary. From the imaging end, the government is further focusing on whether certain imaging services reflect the expenses incurred by a practice and whether the utilization rates for certain practices reflect industry standards.
- Physicians – Specifically as it relates to physicians and advanced practice providers, the government has noted consistent problems with place of service codes. This means that certain claims for services performs in ambulatory surgery centers or hospital outpatient departments did not always include the specific and correct place of service code.
These are just a few of the many examples in this report and it is highly advisable that all healthcare providers understand this report, as well as the numerous laws that relate to healthcare fraud and abuse. In addition, every organization needs to ensure that it has an effective compliance program in place to ensure that issues such as these are dealt with immediately. The recent guilty plea by a solo physician highlights that these issues should be important to all organizations from large health systems to solo practices.