Knowledge Base Article

I remember from my first year as a compliance officer, a hospital representative lecturing at a national compliance conference explained how her facility made unintentional errors in the assignment of Medicare patients’ discharge statuses that were interpreted by the government as fraudulent activity. Now she could have presented a skewed interpretation and I am, in no way, questioning the government’s conclusion of any of the cases below. I am just acknowledging that sometimes, different parties have differing interpretations of how certain activities are classified.

The Health Care Fraud and Abuse Control Program 2012 Annual Report, a collaboration between the Department of Health and Human Services and the Department of Justice, highlights the successes of the government’s program to identify, prosecute, and prevent healthcare fraud and abuse. Below is a summary of the issues that resulted in settlements by hospitals to resolve claims and allegations under the False Claim Act (FCA).

1. Two settlements (almost $25M) relating to inflated fees for services that resulted in inappropriate Medicare “outlier” payments. The report states that both hospitals manipulated their charge structures to make it appear as though their treatment of certain patients was unusually costly, when in fact it was not.
2. Four settlements (over $31M) resulting from medically unnecessary inpatient admissions for patients that could have been treated as hospital outpatients. These cases include patients receiving Gamma Knife stereotactic radiotherapy and patients having kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures, or other surgical procedures that could have been performed on an outpatient basis.
3. Four settlements (approximately $6.7M) for a variety of other issues including:
4. Medically unnecessary and dangerous endovascular procedures
5. Surgical services performed in an Ambulatory Surgery Center (ASC), but billed as hospital outpatient surgeries
6. The drug Lupron® billed with the wrong HCPCS code (note also that even after becoming aware of the issue, these hospitals never self-disclosed or attempted to pay back monies received in error)
7. Improper physician recruitment arrangements.

You can read the full report on the OIG website at HCFAC Report.