Health Care Fraud Information
Our healthcare system is dependent on the role of what are known as “third-party payors”. Those third-party payors include private insurance companies and public entities, including Medicare, Medicaid, TRICARE, and health and welfare funds, which pay for the healthcare needs of Florida’s public employees.
Unfortunately, there are those in the healthcare delivery business who view these third-party payors through the lens of “other people’s money”. This has resulted in a myriad of schemes which amount to fraud, waste, and abuse of healthcare dollars.
A nationwide analysis of these schemes indicates that healthcare fraud, waste, and abuse is rampant at every tier of the healthcare delivery system. From doctors, clinics, testing and imaging services, nursing homes, hospitals, pharmacies, drug and device manufacturers, have all been implicated in conduct that amounts to healthcare fraud. Yet, it is not just about money. Schemes designed with an eye toward monetary gain too often are implemented at risk to patients. The residents of Florida need to be the eyes and ears for enforcement compliance and look for the following fact patterns:
- Doctors: Third-party payor reimbursement for doctors is often dependent on a coding system. Patients who are coded with specific illnesses or treatments qualify to have their doctor reimbursed at a specific level. Doctors sometimes engage in schemes called “upcoding,” which involves using billing codes that allow the doctor to be reimbursed for a costlier service than the one that was actually provided. Moreover, where patients participate in a Managed Care network, doctors may engage in schemes to diagnose the patients with acute problems in order to achieve a higher reimbursement rate. These schemes cost the State and Federal government billions of dollars each year while creating imprecise records that may impact healthcare delivery.
- Kickbacks: Federal law makes it unlawful for a fee to be provided to induce the use of services where reimbursement, in whole or in part, is with Federal dollars. Doctors cannot take referral fees from companies that provide x-ray services, imaging services, or any other diagnostic testing. Such referral fees are deemed “kickbacks” and violate the anti-kickback statute *LINK TO STATUTE. Similarly, the law precluded doctors from waiving copays for patients whose healthcare is covered in whole or in part with Federal monies, including Medicaid, Medicare and TRICARE. The law also precludes pharmaceutical and device manufacturers from providing benefits to doctors or to others in order to induce the use of their products. Often, these benefits are disguised as activities that – at first glance – seem legitimate. For example, consulting fees, speaker fees, and the provision of gratuities in the form of gifts can violate the anti-kickback statute.
- Hospitals: Hospitals have been a hotbed for waste, fraud, abuse, and conduct that has placed patients at risk. Hospitals have been held liable –and paid fines – for unnecessary admissions from the emergency room. Hospitals have similarly been held liable for billing for the services of attending physicians when the treatment was rendered by residents – another form of “upcoding”. Hospitals can also be held liable for billing for services that were not rendered or rendered improperly. And, the government is also concerned about surgeons who engage in concurrent surgeries in contravention of the specific Medicare guidance covering those surgeries.
- Ambulance services: It is not a well-known fact that when the average citizen dials 911, the phone is being answered by a private contractor that provides ambulance services. Too often, these contractors engage in transportation that is not medically necessary and too often, they check boxes on billing forms in order to make false representations about the medical necessity of the service.
- Drug companies: Every drug that’s placed on the market has what is known as an FDA-approved indication. After the submission of extensive data, the FDA approves a drug to treat a specific malady and for its specific use. The indication is specific as to disease state, dosing, and whether the medical regiment is a monotherapy or done in conjunction with other drugs. Marketing a product within the four corners of its FDA label is required by the Food, Drug, and Cosmetic Act. Yet, sticking within the four corners of the law limits a manufacturer’s ability to make money. Drug companies routinely engage in schemes that are tantamount to marketing their drug for purposes outside the indication. A manufacturer engages in “off-label marketing” when it tells its sales representatives to compete a product with another product having a different indication. Off-label marketing also occurs when sales representatives, agents of manufacturers, or other entities acting on behalf of a manufacturer encourage or hint at uses that vary in any way – including dosing regimen – from the FDA-approved package label.
- Drug company kickbacks: Manufacturer kickbacks is a topic that deserves its own attention – too often, drug companies launder money to doctors and others who can influence product utilization under the guise of speaker programs, consulting agreements, and even participation in trials. Getting the money into the doctors’ hands through any mechanism is critical to influencing medical treatment. Though doctors claim that they are never influenced by these payments, studies have shown that payments to doctors does, in fact, influence product utilization.