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HEALTH CARE FRAUD: THE FALSE CLAIMS ACT AND NURSING HOME FRAUD
JOE A. FLORES, Esq., RN, MSN, CCRN, FNP, JD
Copyright 2006
INTRODUCTION
- America is aging
- 1.6 million elderly and disabled are cared for in nearly 17,000 nursing homes
- A significant number of americans will rely on medicare and medicaid to pay for these services
CRIMINAL LIABILITY
- The General Accounting Office (GAO) estimated that in 1996 approximately 10 percent of the federal budget was lost to fraud and abuse in federal healthcare reimursement programs
FALSE CLAIMS ACT
- an antifraud statute
- aka Lincoln’s Law
- has been amended several times; most recently in 1986
- this law has been used most frequently to fight medicare fraud
- the 1986 amendment to the false claims act has made it easier for the “little guy” to report false claims and assist the government to fight fraud
- qui tam: latin phrase, “he who brings an action for the king , as well as for himself”
- qui tam relators may bring lawsuits on behalf of the federal government to recover money that has been obtained by defrauding programs such as medicare
- since 1986 billions of dollars have been recovered by “whistleblowers” using the qui tam provisions of the false claims act (31 u.s.c. sec. 3729, et seq)
THE MECHANICS OF REPORTING UNDER THE FALSE CLAIMS ACT/QUI TAM
- strict pleadings
- nondisclosure requirements
- must not have already been disclosed publically or by another relator
- filed under seal at least 60 days
INCENTIVES FOR REPORTING FALSE CLAIMS
- government incentives
- act provides for 15-30 percent of the amount received back to the government
- the government may or may not intervene
EXAMPLES OF FRAUD UNDER MEDICARE AND MEDICAID
- most involve physicians, hospitals or healthcare workers
- hcp’s billing services not covered by medicare and medicaid
- upcoding by physicians and other hcp’s for services that are routine which are then billed as special services so as to upcode that service
- billing for durable medical equipment that was not provided to a patient
- documenting on patients in a nursing home for services never or almost never rendered
- unbundling lab tests ordered by a physician as a “panel” to bill separately for each test
NURSING HOME FRAUD
- nursing home billing for physical, respiratory and occupational therapy services that were not provided to the resident as well as for dme
- not limited to medicare and medicaid; also includes military defense (100 dollar hammers), welfare, road construction and housing and urban development
HOW DO WE CATCH THE BAD GUYS?
- false claims
- conspiracy
- mail fraud
- wire fraud
- rico
FALSE CLAIMS
- federal law prohibits a person from knowingly presenting to the government a false or fraudulent claim for payment or reimbursement
- felony which can result in five years of imprisonment and a severe fine
CONSPIRACY TO DEFRAUD
- prohibits an individual from entering into an agreement to defraud the government by aiding or obtaining the payment or allowance of a false or fraudulent claim
- long term care: facility asks its nurses to document skilled care in situations which only require non-skilled care which results in false billing of Medicare Part A.
- the crime is a felony and is punishable up to five years in prison and severe fines
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