An acute care hospital in Oklahoma has paid over $1.1 million to settle allegations that it violated the False Claims Act by submitting false claims to Medicare.
Following an internal review and audit, the hospital discovered irregularities regarding its billing of certain services, and proactively contacted the United States to self-disclose the issues. The United States Attorney’s Office and the US Department of Health and Human Services Office of Inspector General (OIG) then investigated the disclosures and issues raised by the hospital. Throughout the investigation, the hospital cooperated with the above entities.
The voluntary disclosure and investigation revealed that from June 1, 2013, through May 31, 2019, the hospital submitted claims to Medicare for Intensive Cardiac Rehabilitation (ICR) services provided to Medicare beneficiaries. Before billing Medicare for these services, the hospital was required to have a physician complete and sign an individualized treatment plan (ITP) for the patient. If the patient was going to receive ICR for longer than 30 days, a physician must complete and sign updates to the ITP every 30 days thereafter. The United States alleges that claims for ICR services submitted by the hospital to Medicare for payment violated the False Claims Act because a physician did not complete and/or sign ITPs and/or ITP updates for certain Medicare beneficiaries.
The hospital agreed to pay the United States $1,151,770.50 to resolve the claims. In reaching this settlement, the hospital did not admit liability, and the government did not make any concessions about the legitimacy of the claims. The agreement allows the parties to avoid the delay, expense, inconvenience, and uncertainty involved in litigating the case.
Issue:
False claims can be generated in a variety of capacities. It is important for staff to be aware that false claims can occur whether they are intentional or unintentional. All physician orders, including treatment orders, must be signed and dated before submitting the claim to Medicare. Healthcare providers, suppliers, or other individuals or entities subject to Civil Monetary Penalties can use the OIG’s Provider Self-Disclosure Protocol to voluntarily disclose self-discovered evidence of potential fraud. Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.
Discussion Points:
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
