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Work In Healthcare? You Could Face Steep Fines Or Jail Time For Healthcare Fraud

Healthcare FraudNewly Released Health Care Fraud Report shows that HHS/DOJ Enforcement Efforts Remain Strong

The Department of Health and Human Services (HHS) and the Department of Justice (DOJ) recently released their annual joint report outlining the results of their healthcare fraud enforcement efforts throughout FY 2015.

The Report shows that during that period the DOJ opened 983 new criminal health care fraud investigations and over 800 new civil health care fraud investigations. Additionally, HHS investigations resulted in 800 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 667 civil actions, CMP settlements, and administrative recoveries related to provider self-disclosure matters.

Over the course of the year, the government won or negotiated over $1.9 billion in health care fraud judgment and settlements.

High Number Of Fraud Convictions

The Report also highlights the activity of the Medicare Fraud Strike Force whose efforts resulted in over 300 guilty pleas and 48 defendant convictions throughout the year, and over 260 defendants going to jail. The Report summarizes several successful enforcement actions by the Strike Force including:

  • 2 physicians owners of a mental health clinic were each sentenced to 10+ years in prison for certifying that certain Medicare patients qualified for partial hospitalization services when they did not and paying kickbacks to group home operators and patient recruiters in exchange for referring Medicare patients;
  • An owner of a DME company was sentenced to 84 months in prison for paying kickbacks to medical clinics for fraudulent prescriptions for DME which the patients did not need; and
  • 2 home health directors were sentenced to over 10 years in prison and ordered to pay $18.6 million in restitution after pleading guilty to conspiracy to commit fraud and payment of kickbacks in exchange for Medicare referrals and home health service prescriptions.

You Could Personally Be Fined Or Go To Jail

The government is clearly cracking down and the healthcare industry should heed the warning. The Report indicates that any individual in the healthcare realm, whether physician or hospital CFO, could incur steep fines, penalties and even serve jail time for violating the Federal Anti-Kickback Statute, Stark Law and False Claims Act.

Jeyaram & Associates can help you assess and minimize your risk under these healthcare fraud and abuse laws. If you have any questions please contact Danielle Hildebrand at Dhildebrand@jeylaw.com or 678.325.3872.

To review the Report it is available here.

Are You Compliant? HHS Issues Guidance & Likely To Continue HIPAA Compliance Scrutiny

HIPAA AuditThe Department of Health and Human Services (HHS) started the year by publishing new HIPAA guidance with respect to patient access to medical records.

While the recent HHS guidance does not add anything new to the regulations, it serves as a reminder to providers of certain provisions in the law. The guidance is intended as a tool to aid individuals in exercising their rights to access their medical records and to help providers ensure HIPAA compliance.

HHS highlighted certain provisions in the HIPAA regulations including provider obligations to respond to a request from a patient within 30 days and provide PHI in an electronic format if requested (assuming the electronic format requested can be readily produced by the provider).

The guidance also reminds providers that covered entities are not required to provide every single record about an individual even if the individual asks. Certain exceptions to a patient’s right to access include:

  • Patients do not have the right to access to information that is not used to make decisions about that individual. For example, certain quality assessment or improvement records, patient safety activity records, or business planning, development and management records that are used for business decisions do not have to be provided to an individual.
  • Individuals do not have a right to access psychotherapy notes that a mental health professional maintains separately from the individual’s medical record and that document or analyze the contents of a counseling session with the individual.
  • Providers can deny access to certain records if a licensed health care professional determines in the exercise of professional judgment that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person.
  • Patients do not have a right to access certain records compiled in reasonable anticipation of, or for use in, a legal proceeding.

Additionally, providers do not have to create new information, such as explanatory materials or analyses, that does not already exist in the record.

The government’s emphasis on HIPAA is expected to continue with pending audits of covered entities and business associates likely to take place this quarter. Now is the time for healthcare providers to review their policies to ensure that they are complying with the HIPAA regulations.

If you would like to review the HHS guidance it is available at http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html.

If you need help ensuring HIPAA compliance, please contact Danielle Hildebrand at dhildebrand@jeylaw.com or 678.325.3872.

 

 

Physicians Need To Be Prepared For Increased Medicare & Medicaid Fraud Scrutiny

doctor-in-handcuffs-caption-1HHS increases resources to root out and penalize fraud:  Review existing financial arrangements NOW

On June 30th the federal Department of Health and Human Services Office of the Inspector General announced that it has created a specialized unit comprised of attorneys focused on Medicare and Medicaid fraud. This announcement comes on the heels of the OIG Special Fraud Alert reminding physicians of anti-kickback liability for illegal compensation related to arrangements with healthcare institutions.

Physicians should be prepared for increased scrutiny and an uptick in enforcement actions for kickback violations. According to OIG official Lisa Re, the new unit will be targeting kickback cases and will be going after not only the individual or organization paying the kickbacks but also the recipient of the kickbacks, e.g., the physicians.

Physicians who have financial arrangements that violate the Federal Anti-Kickback Statute would not only be subject to fines in the form of Civil Money Penalties, but could also be excluded from the Medicare and Medicaid programs.

Now is the time for physicians to review existing or proposed financial arrangements to ensure that they do not pose any risk of violating the Anti-Kickback Statute.

If you have any questions about a particular arrangement our attorneys can help. Please call Danielle Hildebrand or DJ Jeyaram at 678-325-3872 for legal counsel.

Increase In Medicare Part D Fraud Investigations

medicare-fraud1On June 18th, the U.S. Department of Health and Human Services announced a nationwide sweep by the Medicare Fraud Strike Force in 17 districts. This sweep represents the largest criminal healthcare fraud takedown in the history of the Department of Justice.

The investigations led to charges against 243 individuals, including 46 doctors and 197 other medical personnel. These individual are charged with participating in Medicare fraud schemes, including prescription drug fraud, totaling approximately $712 million in false billings.

On the heels of this announcement, the Office of Inspector General issued two new reports citing its findings of numerous nationwide violations of Medicare part D, Medicare’s drug benefit program. The reports show that more than 1,400 pharmacies submitted questionable billings for opioid drugs and also point to questionable billing practices in 1,432 retail pharmacies. The OIG is calling for more action from the Centers for Medicare and Medicaid Services to implement a greater number of its recommendations for fighting fraud and abuse in Part D.

The timing of these reports signals that the prescription drug benefit in Medicare part D will continue to be on the radar for investigation and enforcement actions.

To best protect against facing investigation for violations of federal and state healthcare regulations, providers must create, consistently practice and enforce strong internal compliance programs. If you need assistance with developing a compliance program or have any questions about healthcare fraud, please call or email Kimberly Sheridan at 678-708-4702.

 

OIG Reports

https://oig.hhs.gov/oei/reports/oei-02-15-00190.pdf

https://oig.hhs.gov/oei/reports/oei-03-15-00180.pdf

 

Healthcare Providers Need To Examine Billing Practices To Ensure Compliance

healthcare fraudLast month, the Department of Health and Human Services released its annual report for the Health Care Fraud and Abuse Control Program. According to the report, in 2014 more than 900 new criminal health care fraud investigations were opened by the Department of Justice. There was a slight increase in the number of criminal cases and convictions from last year, with 496 cases and 735 defendants convicted of criminal health care fraud. Civil cases alone resulted in $2.3 Billion in settlements and judgments.

The government’s press release reiterated that detecting and eliminating fraud and abuse continues to be a top priority. The government attributes its high recoveries to a change in strategy which uses real-time data analysis to detect fraud more quickly. The Centers for Medicare and Medicaid currently uses advanced analytics on Medicare fee-for-service claims. The goal of this is to detect aberrant and suspicious billing patterns which would then trigger an investigation or enforcement action by the government.

Now is the time to for Medicare and Medicaid providers to review their billing practices and financial relationships to ensure that they are compliant with federal laws. Charges against providers were made under the False Claims Act, as well as Anti-Kickback Statute, the Stark Law (Physician Self-Referral Law), and other federal laws.

The full annual report is available at www.oig.hhs.gov/publications/hcfac.asp.

If you have any questions about the legality of your billing practices or financial relationships, please contact DJ Jeyaram at DJ@jeylaw.com or Danielle Hildebrand at dhildebrand@jeylaw.com.