Tag Archives: ambulance services

Strike Force Busts 89 People, Mostly Health Care Professionals, in Nationwide Crackdown on Medicare Fraud

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In a nationwide takedown nearly 100 people, including doctors, nurses and other medical professionals, in eight cities were all allegedly charged in separate Medicare fraud schemes. These individual scams involved approximately $223 million in false billing, according to the Department of Justice (DOJ) and the Department of Health and Humans Services (DHHS). On May 14, 2013, more than 400 law enforcement officials with the Medicare Fraud Strike Force spread out between Miami, Detroit, Los Angeles, New York, New Orleans, Houston, Chicago and Tampa to make the arrests of these 89 people, according to the DOJ.

Click here to read the press release from the DOJ.

Medicare Schemes Could Not Have Happened Without the Help of Health Professionals.

According to an article in Reuters, one out of every four defendants in this crackdown was some type of health professional. Authorities say most of these allegedly complex scams could not have happened without the participation of a doctor signing off on a bogus service, or a nurse filling out false paperwork.

Click here to read the entire article from Reuters.

Florida Health Professionals Involved.

According to the DOJ, in Miami, a total of 25 people, including two nurses and a paramedic, were allegedly part of numerous Medicare scams, totaling about $44 million in false claims. In one case involving a home health agency, defendants allegedly bribed Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. The DOJ believes the lead defendant spent a majority of the money from the scam on luxury cars.

Phony Health Care Clinics Set Up.

In Tampa, nine individuals were charged in a variety of schemes, ranging from pharmacy fraud to health-care related money laundering. According to the DOJ, in one case four individuals allegedly established four health care clinics. The individuals allegedly used these clinics to steal more than $2.5 million from Medicare for surgical procedures that were never performed.

This Marks the Sixth Time the Medicare Fraud Strike Force Has Executed a Nationwide Crackdown.

This crackdown marks the sixth time the Medicare Fraud Strike Force has taken nationwide action against Medicare fraud. To date, the Medicare Fraud Strike Force is credited with making more than 1,500 arrests on charges related to $5 billion in allegedly false Medicare claims since 2007. According to the DOJ, it’s believed Medicare fraud costs the program between $60 billion and $90 billion each year.

Medicare operates under a pay-and-chase system, but according to the Washington Post, authorities are beginning to use new technology that flags suspicious claims before Medicare makes a payment. To read the entire Washington Post article, click here.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think of these nationwide crackdowns on Medicare fraud? Do you think they work as a deterrent for others committing health care fraud? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Kennedy, Kelli. “Doctors and Nurses Among Nearly 100 Charged in $223 Million Medicare Fraud Busts in 8 Cities.” Washington Post. (May 14, 2013). From: http://www.washingtonpost.com/politics/health_care/doctors-nurses-among-nearly-100-charged-in-223-million-medicare-fraud-busts-in-8-cities/2013/05/14/fbb0de3a-bcbc-11e2-b537-ab47f0325f7c_story.html

Morgan, David. “U.S. Charges 89 People in $223 Million Medicare Fraud Scheme.” Reuters. (May 14, 2013). From: http://www.reuters.com/article/2013/05/14/usa-healthcare-fraud-idUSL2N0DV3GZ20130514

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Ambulance Company in Tennessee Settles A $2 Million Overpayment Lawsuit

George F. Indest III, Board Certified by The Florida Bar in Health Law

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Dr. Thu Pham, O.D., Law Clerk, The Health Law Firm Attorney

A Tennessee ambulance company and the U.S. Department of Health and Human Services (DHHS) announced a settlement in a case over a post payment audit for more than two million dollars in May 2012. Back in March of 2010, the Nashville ambulance company sued the DHHS after being sent a $2.65 million overpayment demand, according to the Nashville Business Journal.

To see the Nashville Business Journal article on the lawsuit, click here.

Huge Fine Found Using Error Rate Extrapolation Formula.

According to the lawsuit, the ambulance company claimed that the fine was based on incorrect accounting by a Medicare Administrative Contractor (MAC) for the DHHS. The contractor reviewed “a small sample of claims and determined that many did not meet Medicare coverage criteria.”

The actual overpayment on those claims was $10,764, which was determined to be an error rate of fifty-one percent (51%). The error rate was then used to extrapolate and obtain the $2.65 million figure which was demanded from the ambulance company.

Ambulance Company Files Administrative Appeal.

Upon administrative appeal, the ambulance company said most of its claims were determined to be appropriate, yet the error rate was never recalculated and the company was still stuck with a large bill.

Disputes of payments included bills for transporting dialysis patients by ambulance. The DHHS said those trips were not valid because they were not emergencies. The ambulance company refuted this contending that the trips did not have to be emergencies because they were ordered by a doctor.

Click here to read the entire lawsuit.

What You Should Know About the Use of Statistical Sampling and Extrapolation Formulas.

In both state Medicaid audits and in Medicare audits, we have experienced increased reliance by the auditing agency on use of mathematical extrapolation formulas to estimate the amount that should be repaid. The formula used usually takes the overpayment that has actually been found and, based on several factors, multiplies it out to many times the actual overpayment amount, as is the example in this case. We have seen ratios of as high as 1 to 150 (or 150 times the actual disallowed claims amount) calculated.

Things you should know about this are as follows:

1.  Neither the Medicare program nor the state Medicaid programs should use an extrapolation formula, unless:

  a. There is a “high” error rate in the claims that have been submitted; or

  b. There have been prior educational efforts or prior audits of the provider, and the provider

has failed to correct the problems in claims submission previously found.

2.  The states each have different guidelines, rules or regulations on when they will apply the statistical formula. Some do not use it at all. Some use a higher percentage error rate to prompt use of the formula and some lower. For example, North Carolina uses one of the lowest percentage error rates we have encountered; an error rate of more than five percent (5%) will prompt its Medicaid agency to apply the statistical extrapolation to the recovery amount.


Two Parties Settle.

On May 25, 2012, the United State District Court announced the ambulance company and the DHHS had settled and compromised. The lawsuit was dismissed against the DHHS without prejudice for a period of ninety (90) days.

Click here to see the order of dismissal.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Nashville Business Journal. “Ambulance Company Sues Over $2.65M Bill.” Nashville Business Journal Online. (March 15, 2012). From: http://www.bizjournals.com/nashville/stories/2010/03/15/daily2.html

First Call Ambulance Service, Inc., v. Department of Health and Human Services, Case Number 3:10-0247, Order of Dismissal, May 25, 2012 available at: http://www.thehealthlawfirm.com/uploads/First%20Call_Dismissal.pdf

First Call Ambulance Service, Inc., v. Department of Health and Human Services, Case Number 3:10-cv-0247, First Call Ambulance Service, Inc., Sues Department of Health and Human Services Over $2.65 Million, March 20, 2010 available at: http://www.thehealthlawfirm.com/uploads/First%20Call%20Case.pdf

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

New Hampshire City Auditing Ambulance Service for Allegedly Overbilling

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On July 16, 2012, a New Hampshire city allegedly launched an audit into its primary ambulance service, American Medical Response (AMR), after the company acknowledged overbilling hundreds of patients since 2011, according to a Union Leader article.

AMR Allegedly Incorrectly Billed More Than 300 Ambulance Trips.

According to the report, an in-house audit by the city showed that 323 ambulance trips out of nearly 5,000 in 2011 and 2012 had been incorrectly billed. This amounts to slightly more than six percent (6%). AMR attributes the overbilling to human error.

After concerns that the billing problems could be more widespread, it was decided the ambulance service should be audited by an independent auditor.

AMR is reported to have forgiven any outstanding incorrect balances and issued $16,000 in refunds to patients who had already paid the incorrect bills.

Patients’ Bills Allegedly Exceeded the Amount AMR was Authorized to Charge.

Residents describe a common bill for ambulance transportation to be more than $1,000 for a single ambulance trip, which is approximately sixty-six percent (66%) more than AMR is authorized to charge under its contract with the city.

The city began its contract with AMR in January 2011, after the city’s previous ambulance service went out of business. The city’s fire chief said that under AMR’s contract, the company cannot charge more than thirty-five (35%) above the Medicare rate.

AMR is allegedly cooperating in the review, but the audit will take about a month to complete.

Ambulance Services Companies Are Easy Targets for Medicare Audits.

Recently, ambulance service companies have become the target of Medicare audits and are frequently accused of billing Medicare for unnecessary services. Medicare and Medicaid audits can result in overpayment demands reaching into hundreds of thousands of dollars and assessment of fines. Ambulance services were included in the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) work plan for fiscal year 2012 as an area that would be subject to scrutiny. Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) are launching audits of ambulance service providers and emergency medical transportation companies.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

Medicare fraud is a serious crime and is vigorously investigated by the FBI and the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG). Don’t wait until its too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, ambulance services companies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Siefer, Ted. “Independent audit begins on Manchester ambulance service billing.” Union Leader. (July 23, 2012). From: http://www.unionleader.com/article/20120724/NEWS06/707249979

Siefer, Ted. “City will conduct audit ambulance service over overbilling.” New Hampshire.com. (July 28, 2012). From: http://www.newhampshire.com/article/20120729/NEWS0603/707299953/1007

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

Hospital to Pay $3.59 Million to Settle False Claims Act Allegations Involving Ambulance Services

By Miles Indest

A hospital located in Columbia, Tennesse, has agreed to pay the federal government over $3.5 million to settle False Claims Act allegations that occurred between 2004 and 2009. The hospital submitted a voluntary self-disclosure to the U.S. Attorney’s Office and the Department of Health and Human Services (DHHS) Office of Inspector General (OIG).

Hospital Voluntarily Self-Reported After Compliance Program Revealed Billing Errors.

The hospital self-reported after its own compliance program revealed billing problems for ambulance services. The hopsital’s audit of billings reported faulty claims and payment for:

  • Ambulance services that were billed with incorrect mileage units;
  • Ambulance services that were not medically necessary or for which medical necessity was not documented;
  • Ambulance services for which a physician certification statement (PCS) was not obtained;
  • Ambulance services for which the requisite signatures were not obtained; and
  • Ambulance services that were assigned an incorrect transport level.

Hospital Works With U.S. Attorney’s Office to Resolve Billing Errors.

After notifying the U.S. Attorney’s Office that billing issues had been discovered, Maury Regional outlined a plan to determine the scope of these issues. The hospital then worked with the U.S. Attorney’s Office to bring the matter to resolution.

Ambulance Services Flagged for Medicare Audits.

In a Medicare audit of a hospital or ambulance company, ambulance services are frequently chosen for review. Ambulance services companies have increasingly become a target for Medicare audits and are often accused of billing Medicare for unnecessary services. Ambulance companies should have a compliance plan in place to assist in detecting any errors. Ambulance companies should also take all measures to prepare for a Medicare audit, before notice of an audit is received. To learn more about preparing for Medicare audits, click here.

Contact Health Law Attorneys Experienced with Medicare Audits and False Act Claims Cases.

The Health Law Firm represents ambulance companies, emergency transport services, physicians, medical practices, pharmacists, pharmacies, home health agencies, nursing facilities, hospitals, and other health provider in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving government health programs (Medicare, Medicaid, TRICARE). The Health Law Firm also represents health providers in False Claims Act cases.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources Include:

Humbles, Andy. “Maury Regional to Pay $3.5 Million to Settle False Claims Act Allegations.” Tennessean. (June 29, 2012). From: http://www.tennessean.com/article/20120629/NEWS21/306290078/Maury-Regional-pay-3-5-million-settle-False-Claims-Act-allegations

Staff. “Maury Regional Hospital to Pay $3.59 Million to Settle False Claims Act Allegations.” The Daily Herald. (June 29, 2012). From: http://www.columbiadailyherald.com/sections/news/local/maury-regional-hospital-pay-359-million-settle-false-claims-act-allegations.html

Man Charged with Medicare Fraud in Ambulance Scheme

By Miles Indest

A Pennsylvania man has been charged in a 23-count indictment in relation to an alleged scheme to defraud Medicare by billing for fraudulent ambulance services. The charges were announced by the Department of Justice (DOJ) on June 29, 2012.

Man Allegedly “Straw” Owner Used to Start Ambulance Company.

According to the indictment the man allegedly used a “straw” owner (someone who was not actually the owner) to fraudulently open Starcare Ambulance because he was otherwise ineligible to own the company. Between 2006 and 2011, the man allegedly billed Medicare for transporting kidney dialysis patients who did not medically need ambulance service. This indictment seeks forfeiture of over $5 million in cash as well as a GMC Hum-V (“Hummer”) vehicle.

Man Could Face Up To 10 Years in Prison for Each Count of Health Care Fraud.

If convicted of all charges, the defendant faces a statutory maximum sentence of ten years in prison on each of the health care fraud and conspiracy counts. He also faces five years in prison for aiding and abetting in false statements relating to health care fraud, a three year term of supervised release, and a fine of up to $250,000.

Ambulance Services Companies Are Target for Medicare Audits.

In recent years, and especially in 2012, ambulance services companies have become the target of Medicare audits and are frequently accused of billing Medicare for unnecessary services. Medicare and Medicaid audits can result in overpayment demands reaching into hundreds of thousands of dollars and assessment of fines. Ambulance services were included in the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) work plan for fiscal year 2012 as an area that would be subject to scrutiny. Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) are launching audits of ambulance service providers and emergency medical transportation companies.

Contact Health Law Attorneys Experienced in Handling Medicare Audits.

Medicare fraud is a serious crime and is vigorously investigated by the FBI and the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG). Don’t wait until its too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, ambulance services companies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources Include:

“Pennsylvania Man Charged With $5.4 Million Medicare Fraud.” San Francisco Chronicle. (June 29, 2012). From: http://www.sfgate.com/news/article/Pa-man-charged-with-5-4-million-Medicare-fraud-3674333.php

Department of Justice, Office of Public Affairs. “Pennsylvania Man Charged with Fraud in Ambulance Scheme.” Department of Justice. Press Release. (June 29, 2012). From: http://www.justice.gov/opa/pr/2012/June/12-crm-840.html