In the legal sense, the term “fraud” connotes deceit and an underhanded act or scheme. When applied to specific areas of law, the elements change but reflect the general principle.
In cases of Medicare fraud, a federal statute entitled the False Claims Act (FCA) applies. Under the law, any person who knowingly submitted false claims to the government has liability.
In the fiscal year ending September 30, the Department of Justice, who enforces the act, collected more than $5 billion.
False Claims Act provides basis for suit
In addition to the United States, the FCA permits private citizens to file suits known as qui tam suits on behalf of the government. Successful qui tam suits permit private citizens to receive a portion of the government’s recovery.
A recent court case transferred to the United States District Court for the Eastern District of Tennessee reveals the complexities of Medicare fraud.
Several relators brought a qui tam suit alleging the defendant had defrauded the United States government by falsifying patient data on a specific information system called OASIS with the intent to collect inflated Medicare reimbursements. The defendant received reimbursement through Medicare for the home health care and hospice services it provides, primarily to elderly patients.
Allegations include falsifying patient data
Reimbursements for home health services occur at 60-day intervals at a fixed rate for each patient. Several factors – patient’s condition, service needs – contribute to the specific rate. The plaintiffs allege the defendants implement a scheme directing facilities to falsify coding of patient’s health conditions, number of therapy sessions and nursing visits for each patient. An example includes adjusting a patient’s symptoms to satisfy how Medicare defines “homebound” and the nature of services provided eligible to an eligible patient. Defendants accomplish this by, among other means, directing coders and clinicians to change entries in the OASIS system and using software to “scrub” data from OASIS.
Older individuals with multiple or prolonged medical conditions remain susceptible to many forms of abuse. Financial abuse arises when health care entities use them as tools for financial gain.
Attorneys who understand the circumstances around which Medicare fraud thrives can offer guidance.