Programs, Health Care Fraud

Health Care Fraud

What is Health Care Fraud?

Fraud in our nation’s health care system, including that in the Western District of Michigan, results in losses of millions of dollars every year from the Medicare, Medicaid, and private insurance programs. Beneficiaries and other recipients of health care pay for these significant losses through higher premiums, increased taxes, and reduced services.

Health care fraud occurs when an individual, a group of people, or a company knowingly mis-represents or mis-states something about the type, the scope, or the nature of the medical treatment or service provided, in a manner that could result in unauthorized payments being made. Examples of health care fraud include:

Billing for services not rendered or goods not provided;

  • Falsifying certificates of medical necessity and billing for services not medically necessary;
  • Billing separately for services that should be included in single service fees;
  • Falsifying plans of treatment or medical records to justify payments;
  • Misrepresenting diagnoses or procedures to maximize payments;
  • Misrepresenting charges or entitlements to payments in cost reports; and
  • Soliciting “kickbacks” for the provision of various services or goods.

Health care fraud may be perpetrated against all types of health insurers and health insurance companies, including Medicare, Medicaid, Blue Cross Blue Shield, workers compensation, and other private entities. Medicare services are divided into Part A and Part B coverage. Part A coverage includes hospital care, home health care, and skilled nursing care; Part B coverage includes physician services, laboratory tests and x-rays, outpatient services, and medical supplies.

In Michigan, United Government Services, LLC, processes Medicare Part A claims, and Wisconsin Physicians Service Insurance Corporation processes Medicare Part B claims. For Part A and Part B, Trust Solutions, LLC, is the Program Safeguard Contractor (PSC). PSC's are contracted with the Centers for Medicare & Medicaid Services to reduce fraud and abuse in the Medicare program. To learn more about Trust Solutions, you may visit their web site at: www.trustsolutionsllc.com (http://www.trustsolutionsllc.com/).

What Is The U.S. Attorney’s Office Doing About Health Care Fraud?

The Office of the United States Attorney for the Western District of
Michigan (USAO), the local branch of the United States Department of Justice, is dedicated to prosecuting individuals, groups of individuals, institutions, and businesses that engage in health care fraud. In that effort, the Criminal and the Civil Divisions of the USAO work closely and effectively with various law enforcement agencies to identify and investigate all varieties of this misconduct; those agencies include the Office of the Inspector General of the United States Department of Health and Human Services, the Federal Bureau of Investigation, the Defense Criminal Investigative Service, the Drug Enforcement Administration, the Internal Revenue Service, the United States Postal Inspection Service, and the Office of the Attorney General for the State of Michigan. The USAO also works collaboratively with investigators and auditors of private insurance companies.

When criminal prosecution is deemed appropriate, a criminal complaint, a criminal information, and/or a grand jury indictment may be issued, identifying the alleged perpetrators and describing with particularity the nature and variety of the health care fraud with which they are charged. Depending upon the results of such criminal prosecutions, the federal judges presiding over the cases may order incarceration of the defendants, along with the payment of criminal fines and restitution amounts for the victims. [See the “Criminal Division” page of this Web site.]

In addition, civil prosecution may be pursued to obtain various forms of relief against the perpetrators of health care fraud, including awards of significant monetary damages (sometimes double or triple the actual amount of the false or fraudulent claims). The civil disposition of false claims charges may also include injunctive and declaratory remedies–that is, preventing the defendants from engaging further in publicly-identified conduct–in addition to temporary suspensions or permanent debarments from participation in Medicare and related programs. [See the “Civil Division” page of this Web site.]

As a result of the investigative and prosecutorial work described above, the Criminal and Civil Divisions of the USAO have obtained the convictions of many physicians, podiatrists, dentists, nurses, psychologists, chiropractors, and even a hospital. They have also secured more than $ 32 million in criminal fines and civil damages–all for various types of false and fraudulent conduct in the health care arena–in the past five years.

Nationally, the United States Department of Justice, in collaboration with other federal and state agencies, recovered approximately $1.8 billion in criminal and civil health care fraud prosecutions in 2002 alone and returned approximately $1.4 billion of that to the Medicare Trust Fund. In 2003, federal prosecutors throughout the country obtained some 500 criminal convictions of individuals and corporations for health care fraud-related actions, and approximately 3200 health care providers were excluded from future participation in Medicare and related federal programs. In 2004, the USAO continues to pursue actively and to remedy effectively instances of health care fraud throughout the Western District of Michigan.

What Can You Do About Health Care Fraud?

For approximately five years, fiscal intermediaries and carriers for Medicare have been required, in virtually all circumstances, to send notices and explanations of benefits to Medicare users and patients. It is critically important that all beneficiaries review and verify the information on these documents–and that they question any entries or notations that are inconsistent with or unrelated to the actual health care services provided. In particular, you should be especially attentive to and questioning of notices and explanations that memorialize:

  • Payments for any medical services, treatment, supplies, or equipment that you did not receive;
  • Dates of service or provision of items that differ from the dates on which you actually received the service or items;
  • Payments for ambulance transportation that was not provided to you; and
  • Duplicate payments for the same service or items or for home medical equipment while you were hospitalized.

In addition, you should be especially cautious if a health care provider tells you that:

  • A test or certain equipment is “free” but your insurance number is required for “record purposes”;
  • The more tests given, the “cheaper” they are;
  • Your insurance company can be convinced to pay for the services rendered or the equipment provided; and
  • Your insurance company will pay for the services rendered or the equipment provided–if an incorrect diagnosis or inaccurate description is communicated to it.

Anything else that strikes you as unusual or troubling about any oral statements or written reports given to you in connection with your medical care should prompt you to take further action to ensure that you are not a victim of health care fraud.

General Contact Information

If you believe that a health care provider has engaged in any of the conduct or practices described above, you should promptly contact the insurance carrier that sent the payment notice to you. Alternatively, you may contact one of the agencies or offices listed below to report the discrepancy, irregularity, or other problem that you have identified:

For Medicare Fraud:

The Inspector General’s Hotline: 1-800-HHS-TIPS (1-800-447-8477)
The Inspector General’s Web site: http://www.oig.hhs.gov

The Inspector General’s Mailing Address:

The Office of the Inspector General
United States Department of Health and Human Services
HHS-TIPS Hotline
Post Office Box 23489
Washington, D.C. 20026

The Michigan Attorney General’s Hotline: 1-800-242-2873
The Michigan Attorney General’s Web sites: http://www.michigan.gov/ag/0,1607,7-164-17334_18152-47188--,00.html; or http://www.michigan.gov/ag

For Quality of Care Complaints:

The Michigan Peer Review Organization Hotline : 1-8700-365-5889
http://www.mpro.org/beneficiary_support/quality_of_care_complaints.php

For More Information about the Medicare Program & Related Issues:

United Government Services: 1-800-531-9695
Adminastar Federal, Inc.: 1-800-270-2313

http://www.medicare.com
http://www.cms.hhs.gov

 

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