Insurer Had to Pay for Not Processing Claims Correctly

May 27th, 2009 by admin

More than $13 million in settlement disbursements mailed to physicians
Highmark and Capital Blue Cross settlements were mailed to physicians Nov. 2008. The Highmark settlement divided approximately $10 million among the 33,871 physicians that submitted clean claims that were not paid correctly and on time, making the share amount for the settlement $20.27. The Capital settlement divided roughly $3.5 million among the 31,619 physicians that submitted valid claims, making the estimated base share amount $5.32.

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Fraud and Abuse in Healthcare

May 14th, 2009 by admin

Kathleen Sebelius, the new head of HHS, recently bragged that at HHS “We estimate that for every $1 we spend to stop fraud in the system, we save $1.55.” The False Claims Act cases return $15 for ever $1 invested in investigations and prosecutions.

For every dollar spent to investigate fraud, recover funds obtained through illegal billings or improper billings, and prosecute these civil cases, fifteen dollars are received in return for every $1.00 spent.

As a result of the higher stakes for the health care industry, many companies have

become more vigilant about their internal operations in an effort to comply

with the law, by creating their own internal compliance department. Hopefully, medical companies are less likely to threaten or intimidate employees who detect apparent fraudulent billing practices now that they are aware that such employees could become whistleblowers.

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New Bill That Passed the Senate on Fraud

May 1st, 2009 by admin

U.S. Fraud Recovery Bill Addresses Healthcare 

The Senate on Tuesday approved the Fraud Enforcement and Recovery Act of 2009, which would give additional resources to law enforcement for fighting fraud and abuse, and strengthens fraud laws and statutes.

The bill’s primary intent is to prevent the growing number of mortgage fraud cases. It also broadens the scope of claims that fall under the False Claims Act. Specifically, the bill would extend the reach of the False Claims Act to include any false or fraudulent claim for government money or property, regardless of whether:

  • Was the claim is presented to a government official or employee?
  • Does the U.S. government has physical custody of the money?
  • Did the defendant specifically intended to defraud the U.S. government?

If the bill does becomes law, it will be easier for the government and whistleblowers to succeed in false claims act cases.

The bill redefines terms in the False Claims Act to more accurately reflect the intent of the law. In particular, the term “knowingly” has been redefined which no longer requires prosecutors to prove specific intent to defraud the government.

The new language specifically states intent is not a requirement of the False Claims Act and the prosecution only needs to show the violator did one of the following, in regards to information:

  • Had actual knowledge of the information
  • Acted in deliberate ignorance of the truth or falsity of the information
  • Acted in reckless disregard of the truth or falsity of the information.

Now the government would not be burdened with the difficult task of proving intent of fraud or abuse.  How can an medical facility show that it acted without “deliberate ignorance” or “reckless disregard” will depend on their complance plan and how they are carried out. Are the medical facilities following the minimal recommendations listed in the compliance plan suggestions listed on the OIG website?

The government has said they are looking more closely at whether an organization has a strong compliance program, and based on the severity of the violation what is the medical facility doing to correct the problem so that it does not happen again. The government can offer some leniency to a medical facility that can prove it properly educated employees on claim submissions.  

 

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