Federal Medicare Fraud Appeals

by Unmesh P. Impact

Have you recently been the victim of Medicaid fraud? What about Medicare fraud? From insurance fraud, over billing, improper billing and false medical claims to improper coding practices, claims adjudication fraud, accepting kickbacks, tax fraud violations, overbilling, Medicare / Medicaid fraud, internet pharmacy violations and improper solicitation of patients, the great appellate lawyers of Brownstone Law possess the education and experience that is necessary to help you win your medical fraud appeal case. Brownstone Law can even help you with inappropriate contact with patients, over-prescribing controlled medication as well as criminal negligence in the practice of medicine. If you are seeking assistance with a medical fraud case, call the good people at Brownstone Law today.

Contact Brownstone Law today to discuss your federal criminal appeal (888) 233-8895.

According to John Hopkins Medicine, “Fraud is defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit.”  Further examples of healthcare frauds are stated as follows:

·     “Misrepresentation of the type or level of service provided;”

·     “Misrepresentation of the individual rendering service;”

·     “Billing for items and services that have not been rendered;”

·     “Billing for services that have not been properly documented;”

·     “Billing for items and services that are not medically necessary;”

·     “Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);”

·     “Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding).”

Health Care Fraud is a very serious crime that has severe punishments ranging from lengthy prison time to hefty fines. Our company has a number of highly experienced defense attorney’s that could help defend you in health care fraud cases and can strategically protect your rights and interests.

Kickbacks, Bribes and Rebates

According to the federal Anti-Kickback Statute, if any provider of health care services “knowingly and willfully offer or pay any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce” it can be considered a federal offense. This includes lease, purchase and patient referral where payments are done through federal health care benefit program funds. Anyone receiving such kickback, bribe, or rebate as well can be convicted under the Federal Law.

Despite the language of the Anti-Kickback Statute that mentions the words “knowingly and willfully”, it has been entrenched by the Patient Protection and Affordable Care Act (PPACA) and federal case law that it is not necessary for an individual to have actual knowledge of the illegal payment taking place. It is because of this act that health care service providers who unconsciously become a part of such illegal kickbacks and rebates might have to face federal prosecution.

The federal Anti-Kickback Statute covers the following forms of “remunerations” –

1.   Free or below fair market value use of clinical space, equipment or staff

2.   Cash payments

3.   In-kind gifts (such as airplane tickets)

4.   Certain marketing commissions

5.   Discounts for services, supplies, or equipment

6.   Payments to family members

The Anti-Kickback Statute despite having a broad scope does not have absolute prohibitions. For instance, W-2 employees can be compensated by the providers (in accordance with enumerated factors and subjected to certain limits) only in cases where the payments would be considered illegal kickbacks when they are being made to a contractor or an independent party. Under this law there is a special provision made to safe harbor certain types of transactions. Moreover, some purchasing arrangements and risk sharing have been exempted from this Statute.

Physician Self-Referrals

The Stark Law imposes additional restrictions on the practicing physicians, unlike the Anti-Kickback Statute that broadly applies to all the healthcare providers in all the various segments of the healthcare industry that comes under the federal health care benefit programs. Under the Stark Law any transactions taking place that could qualify as “physician self-referral” are prohibited. The so called “physician self-referral” is referred to as a referral for “designated health services” that can only be provided by an entity that has formed a “financial relationship” with the referring physician.

For authorities that look forward to cracking down improper billings to Medicare and other benefit programs the Stark Law has proved to be a potent weapon due to its broad scope. This is because the definitions of both “designated health services” and “financial relationship” cover a broad spectrum.

These Designated health services include:

1.   DME and medical supplies

2.   Inpatient and outpatient hospital services

3.   Outpatient pathology

4.   Outpatient prescriptions

5.   Clinical laboratory services

6.   Parenteral and enteral nutrients, equipment, and supplies

7.   Physical therapy

8.   Home health services

9.   Imaging

10.  Prosthetics, orthotics, and related supplies]

11.  Radiology and radiological therapy

Financial relationships that can trigger Stark Law implications include:

1.   Direct investment

2.   Indirect investment (compensation arrangements)

3.   Company or practice ownership

4.   Direct compensation arrangements

The Stark Law (just like the Anti-Kickback Statute) has limited exceptions that would only apply in very specific cases. If you are convicted under the Stark Law, then proving that you can qualify as an exception will be your key defense strategy. Having a sufficient amount of documentation that shows a qualifying financial relationship is necessary to avoid any liability.

Billing for Services, Supplies, or Equipment Not Provided

The Centers for Medicare and Medicaid Services (CMS), DOJ, OIG, Department of Defense (DOD), Medicare Fraud Strike Force, and other federal authorities are some of the key investigators of cases that involve billing for services, supplies, and equipment that are not provided or given to patients. In the context of intentional Medicare and Tricare fraud schemes such practices are widely known as “phantom billing”. However, this could also be a result of non criminal activity like unintentional coding errors, typographical errors, misreading of patient records by the administrative staff, that do not require any federal enforcement action to be taken.

It is critical for your business or practice to get to the bottom of the allegations of fraudulent reimbursement requests for services not rendered or supplies not provided as soon as possible. This is necessary because there could be high chances of the government finding evidences that could connect your business or practice to health care fraud. Our lawyers are well equipped to proactively deal with any mistakes made by someone within your business or practice, and provide you with a tailored defense with the main objective of insulating you, your company, and its employees from any criminal allegations.

 

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Created on Jun 7th 2019 08:09. Viewed 426 times.

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