Texas Hospital System to Pay $431,182.96 to U.S. Government for
Violating the False Claims Act
To resolve allegations of submitting false claims to Medicare for reimbursement of genetic testing panels on surgical patients that were not medically reasonable or necessary, a Texas hospital system will pay $431,182.96.
The allegations resulted from an investigation by the U.S. Department of Health and Human Services Office of Inspector General and the Western District of Tennessee Attorney General’s Office of samples submitted to a Tennessee-based laboratory for genetic testing that were taken from surgical patients during the years 2016 to 2018. The testing caused false claims to be filed with Medicare because the genetic tests were not medically reasonable or necessary.
The False Claims Act, 31 U.S.C. §§ 3729-3733, provides the United States with a cause of action against any person or entity that knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval.
Compliance Perspective
Knowingly submitting false claims to Medicare to be reimbursed for services that are not medically reasonable or necessary is a violation the U.S. Government’s False Claims Act.
Discussion Points:
- Review policies and procedures regarding requests for laboratory testing and what the Centers for Medicare & Medicaid Services (CMS) consider to be medically reasonable and necessary.
- Train staff about policies and procedures that guide requests for laboratory testing and reporting of tests that CMS considers medically unreasonable and unnecessary.
- Periodically audit ordered laboratory tests for residents to determine if any are not medically reasonable or necessary.
FRAUD MODULE 3 – MASTERING LEGAL IMPLICATIONS AND ANTITRUST LAWS
