Medicare Compliance & Reimbursement

It's not just Medicare fraud that comes with a big price tag. National chain Maxim Healthcare Services has agreed to pay $150 million for submitting fraudulent claims to Medicaid and the Department of Veterans Affairs.

Privately owned Maxim admitted to submitting Medicaid and VA claims for services that were never rendered from October 1998 to May 2009, according to a release from the Department of Justice. The Columbia, Md.-based national chain admitted to creating and modifying time sheets to support the false claims; submitting claims through licensed offices for services actually supervised through 13 unlicensed locations; and creating or modifying documentation about caregiver training and qualification requirements.

Under the settlement with the DOJ, Maxim must pay $20 million in criminal fines and $130 million in civil fines to the federal government, 42 states, and the VA. The company filed about $60 million in false claims, the DOJ says. Eight former Maxim employees, including three senior managers, and the parent of a former Maxim patient have pled guilty to felony charges related to the investigation, the DOJ says.

If Maxim fails to comply with its Deferred Prosecution Agreement with the DOJ, Justice may proceed with prosecution of the company. Maxim also entered into a Corporate Integrity Agreement with the HHS Office of Inspector General. And the company must employ an independent monitor, who will review Maxim's business operations and regularly report on the company's compliance with all federal and state health care laws, regulations, and programs.

The DOJ allowed Maxim to enter into a Deferred Prosecution Agreement to settle the charges, "in large part due to the extensive reforms and remedial actions the Company has taken since 2009," Maxim notes in a release. Those reforms include hiring a new CEO, terminating senior executives and other employees responsible for the misconduct, installing a chief compliance officer, overhauling and beefing up its compliance program and training, and much more.

"We take full responsibility for these events set forth in the Deferred Prosecution Agreement and we are pleased to reach a settlement that will allow us to move forward with the important work of caring for our patients and clients who depend on us each and every day," Maxim CEO Brad Bennett says in the release.

Meanwhile, the whistleblower who filed a qui tam suit sparking the investigation can count his $15 million share of the settlement. Richard West, a wheelchair-bound Vietnam veteran with muscular dystrophy, filed his lawsuit when he found his Medicaid benefit maxed out in 2004, reports Fox News. West filed suit only after spending months unsuccessfully trying to get government officials to investigate the problem.

Note: Maxim's DPA is at www.maximhealthcare.com/uploadedFiles/Maxim_Healthcare/Home/Maxim%20DPA.pdf.

Federal Healthcare Prosecutions Could Rise By 85 Percent This Year

It's not just your imagination -- healthcare fraud busts are way up this year. Data obtained from the government show federal health care fraud prosecutions in the first eight months of 2011 are on pace to rise 85 percent over last year, reports the USA Today newspaper. That's "due in large part to ramped-up enforcement efforts under the Obama administration," the paper points out.

Federal officials credit the Medicare Fraud Strike Force program that has recently expanded to include nine cities total. The strike forces operate under the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative.

"We're just going to build on this model, and we're going to hold those responsible who are stealing from the government," the Department of Justice's criminal division Assistant Attorney General Lanny Breuer told USA Today.

The statistics, released by the non-partisan Transactional Records Access Clearinghouse, show 903 prosecutions so far this year, the newspaper says. That number is up 71 percent over the last five years.

Don't get stressed if you get a second overpayment letter from MAC National Government Services, even if you've already sent in the payment.

NGS's "Overpayment Recovery Unit has experienced an increase in inventory due to an unusual number of overpayment requests," the MAC says in a message on its website. "This has created a situation in which refunded payments are not posted to the provider's account prior to the second overpayment request letter being issued or the offset being instituted."

NGS is working its way through the backlog and will "return any funds and interest we may have offset as a result of this situation," the MAC pledges.