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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!