Pediatric Coding Alert

For every dollar spent on health care fraud investigations, the government recovered a whopping $7.90.

Attempts to defraud the Medicaid program are getting ever bolder by the week.

That’s the word from the government’s latest report, entitled The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2012, which indicates that the Department of Health and Human Services (HHS) recovered a record $835.7 million from those who attempted to defraud Medicaid in 2012. With the government now recovering $7.90 for every dollar spent on health care fraud and abuse investigations, it seems clear that such a profit will only inspire the OIG to be even more vigilant in ensuring that medical practices stay on the straight and narrow.

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. “This was a record-breaking year for the Departments of Justice and HHS in our collaborative effort to crack down on health care fraud and protect valuable taxpayer dollars,” said Attorney General Eric Holder in a Feb. 11 statement.

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 https://oig.hhs.gov/publications/docs/hcfac/hcfacreport2012.pdf and https://oig.hhs.gov/oas/reports/region5/51100071.pdf.