Medicare Compliance & Reimbursement

When it comes to dealing with Medicare and Medicaid auditors, a lack of straight talk could lead to a perp walk. Take the case of Dana McGovern, owner of McGovern's Ambulance Service in Calais, ME. McGovern pleaded guilty to 40 fraud and obstruction-related criminal counts after prosecutors accused him of using ambulance run sheets for van transports, counting non-reimbursable destinations (e.g., doctors' offices) as reimbursable destinations (such as hospitals), billing for advanced life support when MAS only supplied basic life support, and other misconduct. When sentencing time came around, the judge slapped him with a steeper sentence based on the fact that he deceived Medicare and Medicaid auditors during an administrative review. On appeal, McGovern tried to counter that rules allowing such sentencing enhancements only apply to criminal investigations - not to routine Medicare/Medicaid audits. The 1st U.S. Circuit Court of Appeals, however, didn't buy it. In U.S. v. McGovern (Nos. 02-2064 & 02-2065), the appellate panel held that lying in health care audits can indeed result in steeper criminal sentences if serious misconduct is uncovered. McGovern now faces more than four years in prison, along with a $729,000 restitution penalty. To see the opinion, go to www.ca1.uscourts.gov/. Lesson Learned: Don't even think about trying to mislead a Medicare auditor.