A Cumberland County, Pennsylvania, man has agreed to pay the United States $900,000 to resolve civil liability for alleged violations of the False Claims Act. Additionally, the Pennsylvania man agreed to be excluded from all federal healthcare programs for 22 years. His exclusion means that no federal healthcare program payment may be made, either directly or indirectly, for any items or services furnished by him or at his direction or prescription.
Between 2017 and 2019, the man, through a group of pain clinics he controlled, caused the submission of false claims for payment to Medicare. Those claims were for presumptive and definitive Urine Drug Tests (UDTs) that were not medically reasonable or necessary and were not used to aid in the diagnosis and treatment of patients.
In March of 2022, in a related matter, the man pleaded guilty to Healthcare Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the US Department of Health and Human Services between 2016 and 2020. He is awaiting sentencing on those charges.
“Civil enforcement is an important tool to recover funds when providers cause improper claims to the Medicare program,” said Maureen Dixon, Special Agent in Charge for the US Department of Health and Human Services, Office of the Inspector General. “HHS-OIG will continue to work with the US Attorney’s Office to ensure the integrity of the Medicare Trust Fund.”
Issue
Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate. One of the most important steps a provider can take is to have a robust internal audit program that monitors and reviews claims. If a provider identifies billing mistakes in the course of those audits, the provider must repay overpayments to Medicare and Medicaid within 60 days to avoid False Claims Act liability. Providers also can disclose billing errors to the OIG through the OIG Self-Disclosure Protocol. The List of Excluded Individuals and Entities (LEIE) should also be checked on a monthly basis to ensure that no current employees have been added to the exclusion list. Placement on the LEIE excludes an individual or entity from employment in a setting that participates in federal healthcare programs, and no program payments may be made for items or services furnished by that excluded individual or entity. If claims are filed that involve the excluded individual, it can result in false claims charges, whether or not the healthcare organization was aware that the individual was on the exclusion list.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim. Review your policies and procedures for screening of potential employees to confirm that they are not included on the OIG Exclusion List. In addition, review your policies and procedures for frequency of checking the OIG Exclusion List for all current employees and vendors. Update policies as necessary.
- Train all staff on the False Claims Act and what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Also, train appropriate staff on your policies and procedures for reviewing the LEIE for all new hires and current staff. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit staff understanding to ensure that they know what they should do if they suspect that a false claim has been submitted, whether intentionally or unintentionally. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress into a false claim. Periodically audit the LEIE to ensure that no current employees or consultants are on the exclusion list. Take immediate action if any are found.
