Medicare Compliance & Reimbursement

A Brooklyn, NY healthcare clinic was raking in cash over the past several years, despite the fact that investigators say its medical director wasn’t even on site to perform the services being billed to Medicare and Medicaid.

The doctor pleaded guilty last week to his role in submitting over $13 million in fraudulent claims to government insurance plans between 2009 and 2012. Although the physician wasn’t at the clinic, the facility billed the services to Medicare and Medicaid under his provider number since he was the medical director, the Department of Justice (DOJ) said in a Dec. 1 news release.

Patients at the clinic “received medically unnecessary physical therapy, diagnostic testing, and other services, which were provided by a physician assistant who was acting without supervision,” the DOJ says in the news alert. Over the three year period, the clinic submitted over $13 million to the government for services including physician office visits “that were not medically necessary and often did not even occur.”

The physician pleaded guilty and now faces up to five years in prison, as well as fines and restitution of well over $13 million.

To read more about the case, visit www.justice.gov/usao/nye/pr/December14/2014Dec01.php. 

Minimum Appeals Dollar Requirements To Increase In The New Year

The minimum dollar amount required for your appeal to go before the ALJ or federal court will increase in the New Year. The amount that must remain in controversy for Administrative Law Judge hearing requests filed before Dec. 31, 2014 is $140. This amount will rise to $150 for ALJ hearing requests filed on or after Jan. 1, 2015, Home Health & Hospice Medicare Administrative Contractor Palmetto GBA says on its website.

The amount that must remain in controversy for review in Federal District Court requested before Dec. 31, 2014 is $1,430, Palmetto notes. This amount will increase to $1,460 for appeals to Federal District Court filed on or after Jan. 1, 2015.