Health Information Management

News: HHS, DOJ report billion dollar fraud settlements

CDI Strategies, April 2, 2015

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$2.3 billion. That’s what the HHS Office of the Inspector General (OIG) and the Department of Justice (DOJ) earned back from healthcare fraud judgments and settlements in fiscal year 2014, according to a March 19 report.

While some of the report details read like a sketchy underworld crime novel—“His Grace Medical Supplies and More” forged patient and physician signatures in order to charge Medicaid in excess of $2.3 million for adult incontinence supplies, for example—other cases highlight the often fine line between true fraud and documentation and billing errors.  

For example, in July 2014, Community Health Systems, Inc., based in Franklin, Tennessee, and its affiliated hospitals (collectively, CHS) agreed to pay a total payment of $98.2 million to resolve allegations that it knowingly admitted patients as inpatients when they should have been treated as outpatients or provided observation care and presented false claims to Medicare for certain inpatient procedures that should have performed on an outpatient basis.

In FY 2014, the DOJ opened 924 new criminal healthcare fraud cases, federal prosecutors filed criminal charges in 496 cases, and convicted 734 defendants of healthcare fraud crimes. Similarly, the DOJ opened 782 civil healthcare fraud investigations.

OIG investigations led to 867 criminal actions against individuals or entities for Medicare- or Medicaid-related crimes. Investigations led to 529 civil actions for false claims and unjust-enrichment lawsuits, civil monetary penalty settlements, and administrative recoveries for matters related to provider self-disclosure. The OIG excluded more than 4,000 individuals and entities from participating in Medicare, Medicaid, and other federal healthcare programs due to federal healthcare program convictions or crimes, patient abuse or neglect, or licensure revocations.

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