DECEMBER 19, 2023. The Department of Health and Human Services. Office of Inspector General, (HHS-OIG) recently released its bi-annual report, covering its actions from April 1 to September 30, 2023. Fraud Fighters will spend the next few blogs covering the highlights of the content released by OIG-HHS, shining a light on the crucial work they do to ensure that over $2 trillion of taxpayer dollars are properly spent to serve more than 150 million Americans who rely on the programs funded by that money.
HHS-OIG’s primary focus is Medicare and Medicaid programs, the largest health insurance programs designed to provide coverage to both older and sick Americans. s. OIG investigates matters such as improper billing practices, medically unnecessary services provided for financial gain, and kickback schemes, with the most common fraud being false claims submitted to these government-funded healthcare programs. In the six-month period covered in the report, OIG-HHS took 414 civil actions against both individuals and companies that did not follow proper health care protocols. They reported over $1.79 billion in investigative receivables that are owed to HHS and more than $460.2 million in non-HHS investigative receivables.
MEDICAID AND MEDICARE FRAUD ACTIONS
The HHS-OIG report detailed the highlights of their enforcement actions of several different types. Today, we are highlighting their Medicaid and Medicare enforcement actions from the report, many of which came about due to diligent whistleblowers exposing the fraud.
Managed Civil Care Case:
In July 2023, Martin’s Point Health Care Inc. (Martin’s Point) agreed to pay $22,485,000 to resolve claims that it submitted false diagnosis codes to Medicare for its Medicare Advantage patients to increase their reimbursements. The United States claimed that from 2016 to 2019, Martin’s Point reviewed the charts of its Medicare Advantage patients and added unnecessary diagnosis codes that were not supported by the patients’ medical records. Aware of this, Martin’s Point still submitted these claims, violating the False Claims Act.
Kickback Civil Case:
In May 2023, Massachusetts Eye and Ear Infirmary, Massachusetts Eye and Ear Associates, Inc., and the Foundation of the Massachusetts Eye and Ear Infirmary, Inc. (Massachusetts Eye and Ear) have agreed to pay over $5.7 million to resolve claims that seven of their physician compensation plans – which involved 44 doctors – violated the False Claims Act. The United States claimed that Massachusetts Eye and Ear compensated those doctors in a way that violated the Stark Law. This law prevents physicians from referring patients to facilities and practitioners with whom they have a relationship and prohibits the referred entity from billing their services to Medicare. This case was brought about due to a whistleblower who filed a lawsuit under the qui tam provisions of the False Claims Act.
HHS-OIG’s work relies heavily on whistleblowers speaking up against wrongdoings they witness to hold those who misspend or cause to be misspent Medicare or Medicaid funds accountable and recover taxpayer funds. Whistleblowers help protect taxpayer dollars and also uphold the integrity of government-funded healthcare programs. Whistleblowers who call out kickback schemes ensure healthcare providers’ decision making is free of ill-gotten financial gains. Under the False Claims Act, whistleblowers are protected from retaliation and may be entitled to a percentage of the government’s recovery in a case.
If you would like to report healthcare fraud, including Medicare or Medicaid fraud, you can contact attorneys at Tycko & Zavareei LLP. Eva Gunasekera and Renée Brooker are former officials of the United States Department of Justice and prosecuted whistleblower cases under the False Claims Act. Renée served as Assistant Director at the United States Department of Justice, the office that supervises False Claims Act cases in all 94 United States District Courts. Eva was the Senior Counsel for Health Care Fraud. Eva and Renée now represent whistleblowers. For a free consultation, you can contact Renée at [email protected] (tel.: 202-417-3664) or contact Eva Gunasekera at [email protected]. You can also go to Tycko & Zavareei LLP’s website for whistleblowers to learn more at www.fraudfighters.net.