Category: Settlements

Inpatient vs. Outpatient: Another Medical Center in Hot Water with Medicare

Medicare is a federally sponsored program designed to help Americans pay for healthcare costs. Although the government strives to provide the best and most affordable care possible, fraudulent billing by healthcare providers drives up costs for covered patients. The Medical Center of Central Georgia overbilled Medicare for services for several years, and the federal government wants its money back.

The Government’s Case

According to the US Department of Justice, the Medical Center of Central Georgia violated the False Claims Act when it overbilled Medicare between January 2004 and August 2008. They claim that the hospital billed Medicare for expensive short-stay inpatient services instead of less costly outpatient services between those years. Inpatient services apply to patients admitted to the hospital for longer than 24 hours due to an illness or injury; outpatient services apply to patients who stay in the hospital for very short periods or who come to the hospital for a simple outpatient procedure. The hospital billed Medicare for inpatient services when the services provided did not meet the criteria.

The Hospital’s Compliance Program

A representative from the Medical Center of Central Georgia said that the hospital takes compliance with the False Claims Act very seriously. The current program consists of a 100% pre-bill review of all inpatient orders as well as a team of physician advisers. According to the hospital, determining whether services rendered are inpatient or outpatient services is difficult, and many hospitals have settled similar claims with Medicare in past years. The attending physician who is on duty at the hospital ultimately decides whether to admit patients. As it turns out, these decisions – as well as the proper billing for them – are incredibly complex.

The Verdict

To avoid complicated and expensive litigation, the Medical Center of Central Georgia settled with the government to the tune of $20 million, a huge sum of money that will go back into the program to help patients. The hospital also agreed to provide employees with additional training in billing compliance for the next five years as part of a corporate integrity agreement. What’s more, the hospital will staff an unbiased, independent third party to review all of its claims for services rendered to federal healthcare program recipients.

The False Claims Act took effect in January 2009 and has since helped the federal government recover a sum exceeding $24 billion. More than half of that comes from cases involving fraud. The federal government is not the only entity relying on the integrity of healthcare providers; the patients must trust their doctors and other team members to bill services properly to avoid the rising costs of healthcare in this country.

If you know of a case of health care fraud, contact an experienced Health Care Fraud attorney at Bothwell Law Group today!

With the costs of health insurance increasingly on the rise despite federal regulations designed to provide affordable healthcare to everyone, companies like Life Focus Center are spending precious taxpayer dollars without the taxpayer’s knowledge. Falsely billing an insurance company, including state-funded Medicaid programs, is a crime – and it carries significant repercussions.

What Is Life Focus Center?
Life Focus Center was a Charlestown non-profit provider of day rehabilitation services to individuals with developmental disabilities, and its goal involved helping these individuals reach their optimal levels of capabilities on the physical, social, cognitive, and even occupational levels. A licensed registered nurse, an occupational therapist, a physical therapist, and a speech and language therapist provided care. According to Life Focus Center, they billed their sessions in 15-minute increments.

Why Was the Billing Fraudulent?
The state of Massachusetts’ Medicaid program, known as MassHealth, forbids day habilitation providers from billing for cancelled or missed sessions, and it also requires healthcare service providers to report the actual amount of time each person in the healthcare team actually spent with the patient. As it turns out, Life Focus Center fraudulently billed more hours of service than provided between 2008 and 2011, a clear violation of the Massachusetts False Claims Act. During this time, the rehabilitation center was involved in a scheme in which it wrongly billed MassHealth for services that it never rendered to a member who either did not attend or attended only very rarely.

The Final Verdict
The investigation of Life Focus Center began with a referral to the Massachusetts Attorney General following a review of the center’s records. Assistant Attorney General Angela Neal and Gregory Matthews from the Attorney General’s Medicaid Fraud Division investigated along with the help of MassHealth and the state auditor. The center closed its doors in 2012, but Bay Cove Human Services subsequently took over and resumed operation. Life Focus Center is no longer a MassHealth provider, and in a settlement between the company and the state, they paid more than $94,000.

Whether the fraud was intentional or the result of poor bookkeeping, it cost the state nearly $100,000 that could have been put to use elsewhere. Fortunately, a review of the billing and a subsequent investigation put a stop to the fraudulent claims, saving the state of Massachusetts and its resident taxpayers tens of thousands of dollars.

If you know of Insurance Fraud in Georgia, contact Bothwell Law Group today for a free consultation.