A West Virginia ophthalmologist and his practice have paid $907,074.64 to resolve allegations that they submitted false claims to Medicare and Medicaid.
From January 13, 2013, through April 12, 2019, the ophthalmologist routinely administered vascular endothelial growth factor inhibitor injections into the eyes of patients to treat purported wet age-related macular degeneration (Wet-AMD) or other ophthalmological conditions for which treatment with such injections is indicated. These injections were not medically necessary because the patients in question did not have treatable Wet-AMD or any other condition that would have warranted the invasive treatment at the time it was administered.
The ophthalmologist was identified by HHS-OIG as one of the top outliers for billing the Medicare program across all medical specialists in West Virginia, far exceeding the average of Medicare claims submitted by his peers. The vast majority of payments he received from Medicare were for injections for purported treatment of Wet-AMD.
The case was investigated by HHS-OIG and the Federal Bureau of Investigation (FBI) in collaboration with the United States Attorney’s Healthcare Fraud Task Force, which brings together federal, state, and local law enforcement partners from numerous agencies to coordinate intelligence sharing and prosecution of healthcare fraud impacting Medicare, Medicaid, and other public healthcare programs.
Issue:
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
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. 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. Review your annual PEPPER (Program for Evaluating Payment Patterns Electronic Report) report to ensure your facility is not an outlier for Medicare billing compared to peers. Patterns of concern may indicate either over payments or underpayments are being received. Use this information as part of your auditing and monitoring efforts to prevent fraud, waste, and abuse of government funds. More information is available at PEPPER Resources (cbrpepper.org).
