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Medical professionals accused of defrauding the government of $900 million

Written by: Kimberly Commito on Tuesday, July 5, 2016 Posted in: Home Infusion, Specialty Pharmacy

Revenue cycle management image-01A typical day for a home infusion provider or specialty pharmacist involves ordering supplies and medications for patients, delivering medical treatments to those patients, and billing insurance and other payers for the services provided. However, this was far from the case for some, according to the Department of Justice (DOJ), which recently charged 61 licensed medical professionals and many others of $900 million dollars in false billings.

The charges occurred as a result of a nationwide sweep led by the Medicare Fraud Strike Force in 36 federal districts. In all, 301 suspects were charged, making this the largest healthcare fraud scandal in U.S. history due to the number of defendants and the dollar amount involved. According to statements from Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell, the charges involve various medical treatments and services, including home health care, durable medical equipment (DME), prescription drugs, physical and occupational therapy, and psychotherapy. Allegedly, the defendants billed Medicare and Medicaid for medically unnecessary services that were often not even provided to patients and pocketed the revenue for their personal gain. (1)

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In Tampa, Orlando, and the Middle District of Florida, some 15 individuals were charged with participating in compounding pharmacy fraud and intravenous prescription drug fraud. According to the DOJ, the fraudulent billing totaled nearly $17 million. In one case, the owner of several infusion clinics billed Medicare for $11.1 million worth of intravenous prescription drugs that the clinic never even bought and obviously never administered to patients. The result of this case is that Medicare paid over $8.6 million dollars in fraudulent claims and the business owner is now under arrest and will be tried in the Middle District of Florida Court. (2)

In the Southern District of California, five suspects, including a doctor and a pharmacist, were charged in a scheme to pay bribes and kickbacks to doctors in exchange for prescribing expensive durable medical equipment and compound pain creams that were not medically necessary. The indictment alleges that approximately $27 million in false and fraudulent claims were submitted to insurers. (3)

And these are just a few of the many cases set to be tried around the country. They are also the reason that all providers have to contend with audits, denials, and scrutiny from Medicare and secondary payers for proof of medical services provided. Although it is not fair to punish the entire healthcare system for the actions of a few, it is the reality we face today. Now more than ever, you must have safeguards in place for your intake and billing teams to ensure that all claims and supporting documentation are complete before you bill so that your reimbursements are not stalled in the process.

See how CareTend ensures that all of your billing requirements are met, so you stay compliant and increase your profits the right way and within the law.


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