Healthcare Compliance Perspective – False Claims:
The Compliance Officer should verify with the Compliance Committee that the policies and procedures pertaining to submission of claims for reimbursement from Federal and State providers are detailed, accurate and verified to avoid improper coding. Education should be provided to therapists and appropriate office personnel as new hired employees and periodically during the year regarding accurate coding for services provided to residents. Audits of therapists’ documentation for provided services and personal surveys with residents receiving services should be performed randomly at least quarterly each year or more often if indicated. Audits of claims submitted for accuracy in coding should be performed quarterly each year or more often if indicated.
A Florida-based wound care service provider with clinics located nationwide, agreed to pay $398,162.69 to resolve False Claims Act allegations pertaining to improper coding. These allegations are claimed to have occurred from January 1, 2012 through June 30, 2017. The healthcare provider is accused of submitting claims to Medicare, Medicaid and Tricare using Modifier 25 to signify that a separate evaluation and management service was performed on the same date as another procedure. However, no such separate service was performed.
This wound care service provider is purported to be one of the largest providers of advanced wound care services in the United States. It is reported that more than 330,000 patients each year are treated through its network of wound care centers and affiliated companies.
Because a private citizen filed a qui tam, or whistleblower, lawsuit raising the civil allegations, the wound care provider agreed to pay the whistleblower’s law firm $48,694.37. In this case, the whistleblower is entitled to receive $91,577.42 of the settlement based on the qui tam provisions of the False Claims Act.
It is noted that the claims settled by this agreement are allegations only, and there has been no determination of liability.
