How the Federal Government Fights Health Care Fraud

Medicare fraud is a topic that is receiving increasing attention from authorities and news media alike. Our California Medicare fraud law office believes this attention is rightly placed and we support efforts to both recover wrongfully diverted funds and prevent future frauds. Two of the ways that the government accomplishes these interrelated goals is through rulemaking and through intervening in whistleblower-led health care fraud claims.

Rulemaking – New Rule Limits Enrollment by Suspect Entities
Last week, the Center for Medicare and Medicaid Services (“CMS”) announced approval of a new rule that will allow the agency to prevent future frauds by identifying persons/entities that pose particular risk to the integrity of our federal health care programs. The rule, as detailed in a CMS Fact Sheet, attempts to prevent suspect groups from enrolling in or remaining part of the system and being permitted to bill Medicare for services provided to beneficiaries. Key elements include: Denying enrollment of providers and others associated with an entity that has an outstanding Medicare debt; Denying or revoking billing privileges of groups that have a managing employee who was previously convicted of certain felonies; and Revoking the billing rights of providers and suppliers that show a pattern of improperly billing for services that fail to meet program requirements.

Additionally, the newly finalized rule works to bring consistency to the effective date on which enrollees can submit bills to the system. This rule changes the previous policy of allowing ambulance suppliers to bill for services provided a year prior to enrollment to make it match the more commonly applied rule limiting filings to after the enrollment application date or the date the group began providing service at a new location. Ambulance providers will also, like other provider types, be required to file all outstanding claims within 60 days of their billing privileges being revoked. CMS predicts this rule alone will save $327 million per year.

Litigation – Government Partnering with Private Whistleblowers
Through rulemaking, CMS seeks to prevent future frauds. On the other side of the coin, False Claims Act litigation is one tool for addressing already-occurred frauds and recovering wrongfully diverted funds. Despite what seems to us a bit of an unfortunate title, an article published by the New York Times on December 1 highlights the partnership between the federal government and private whistleblowers: Tattletales Embraced as Whistle-Blower Programs Gain Support. The Times notes that the government has stepped up efforts to embrace whistleblowers and the Department of Justice is touting a record $5.69 billion in False Claims Act recoveries last fiscal year including $2.3 billion recovered in health care fraud matters. Many of these matters were brought to the government’s attention by private whistleblowers and the government shared some $435 million with these individuals in recognition of their efforts last year and the 1,400 qui tam actions filed in the last two years. These whistleblower partnerships are critical to ending fraudulent schemes and the law reward whistleblowers with both protection and financial compensation for their efforts (amounts vary based on whistleblower involvement, whether or not the government intervenes as plaintiff). Last year saw a 10% increase in tips presented with one award stretching to $30 million for information that would have been nearly impossible to detect without the insider’s aid.

A Law Firm for the Truth Tellers
“Tattletale” is a bit of a dirty word, we’d suggest Truth Teller. No one called Woodward & Bernstein tattletales. Rulemaking looks ahead, using new lessons to prevent future harm. Civil fraud suits, such as health care fraud claims brought via the False Claims Act (“FCA”), look back and attempt to remedy crimes already done. If you have information about a scheme that is defrauding federal or state programs, you can play an important role in recovering lost funds. If you are interested in learning more, call Attorney Brod at his Northern California Medicare fraud firm. While this post has focused on Medicare issues, we do work on cases involving other frauds such as price fraud in procurement contracts, questionable parts provided in defense agreements, and much other area under the FCA and similar statutes. Call our San Francisco, Oakland, or Santa Rosa government fraud law offices to arrange a consultation at our offices or, particularly if you are a bit outside our region, a location amenable to you.