Medicare Compliance & Reimbursement

Government Trying to Recoup More Medicaid Dollars

If you think Medicare is the only government payer coming back to recoup overpayments, think again.

In its report The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2012, the Department of Health and Human Services (HHS) notes that it recovered a record $835.7 million from those who attempted to defraud Medicaid in 2012. The unprecedented amount of Medicaid dollars recouped was included in the government’s total $4.2 billion that it recovered from practices that fraudulently billed federal healthcare programs.

Among the government’s recoveries from Medicaid-participating practices, HHS revealed the following case in its recent report: A North Carolina woman was sentenced to three years in prison and ordered to repay $1.1 million that she had billed to Medicaid for mental and behavioral health services that she was not licensed to perform. She also recruited other Medicaid-approved providers “to defraud by agreeing to submit false and fraudulent claims to Medicaid under their provider numbers for services which the unlicensed woman supposedly rendered,” the report states.

Interestingly, the report was released right around the same time that the OIG issued a separate document stating that CMS is behind on collecting $225.6 million in Medicaid overpayments that were identified prior to 2010. The OIG urged CMS to follow up on collecting those overpayments, so if you believe you’ve collected too much from Medicaid, know that the government may come calling for a refund soon.

Resource: To read the OIG’s complete reports, visit oig.hhs.gov/publications/docs/hcfac/hcfacreport2012.pdf and oig.hhs.gov/oas/reports/region5/51100071.pdf.

Physician Ordered To Pay $6.7 Million And Spend 50 Months In Federal Prison

Whether you launder the money or not, ill-received government health care dollars will always come out dirty.

That’s the conclusion from the trial of a West Virginia physician who fraudulently billed the Medicare and Medicaid programs for pain management services and then transferred the money offshore to avoid paying taxes on it. The doctor’s wife was also convicted of assisting her husband in laundering almost $4 million in healthcare fraud proceeds, a Department of Justice news release indicated.

The physician not only faces 50 months in federal prison, but must forfeit $3.7 million to the government and also make restitution in the amount of $3.1 million to the programs he defrauded, including Medicare and Medicaid.

To read the complete news release about the case, visit www.justice.gov/usao/wvn/news/2013/march/Adams.pdf.

FBI Busts HHA Owners For Fraud, Bribery, Money Laundering

A federal investigation has led to 11 arrests in a large-scale Medicaid fraud scheme involving two for-profit home health businesses, announced the New Jersey U.S. Attorney’s Office. The defendants are facing a myriad of charges, including health care fraud, money laundering and bribery.

“Today’s arrests are the result of a four-year investigation into a sophisticated scheme, involving multiple layers of fraud, money laundering and bribery, in order to defraud the New Jersey Medicaid program of millions of dollars,” Federal Bureau of Investigation acting special agent in charge for Newark David Velazquez said in the Feb. 7 announcement.

Along with nine other conspirators, HHCH Health Care Inc. owner Irina Krutoyarsky and People Choice Home Care Inc. owner Paul Mil allegedly defrauded Medicaid by submitting claims for services not actually provided and obtaining fraudulent home health aide certifications for employees and others. Additionally, the HHA owners purportedly used illegal aliens and non-certified individuals to provide home health aide services and erroneously billed Medicaid for those services.

Krutoyarksy also allegedly bribed a New Jersey Department of Labor employee on two occasions to halt wage-and-hour investigations into HHCH and People Choice. But unbeknownst to Krutoyarsky, the DOL employee was cooperating with the FBI.

The defendants face 20 years in prison and a $250,000 fine for each count of conspiracy to commit health care fraud; 10 years in prison and a $250,000 fine for each bribery charge; 20 years in prison and a $500,000 fine for the conspiracy to commit money laundering charges; and five years in prison and a $250,000 fine for the charges of conspiracy to unlawfully structure financial transactions.

Know Your Flu Shot Basics

Confused about billing for seasonal vaccinations? A new job aid from Medicare Administrative Contractor National Government Services may help.

Remember: Medicare covers one vaccination per flu season, NGS says in the aid. That means a beneficiary could receive more than one flu shot in a 12-month period.

To access the aid, go to www.ngsmedicare.com, choose the “Resources” menu in the toolbar, and click on “Tools and Materials.” The aid is under the “Claims, Billing and Payment” section.