Prosecuting health care fraud is a top priority for the federal government and it should be. Fraud and abuse of taxpayers money cannot be toloerated. News stories abound about federal government fraud enforcement activities against hospitals, clinical laboratories, durable medical equipment suppliers, hospices, and home health agencies. Based on recent legislation to enhance enforcement capabilities, there is reason to expect even more government enforcement activity in the future. While federal fraud investigations and enforcement actions against individual physicians have been isolated thus far, physicians and their practices are not immune to such government actions. Therefore, physicians and others involved in providing patient care need to know how to comply with the federal laws to guard against potential liability in fraud enforcement actions.
However, there are numerous cases which the government calls "fraud" which simply are mistakes. We recently defended a man charged with health care fraud in federal court in Hattiesburg, Mississippi. The government alleged that he had been improperly billing for 4 years and charged him criminally. However, the proof at trial showed that Medicare was aware of our client's billing problems very early on but continued to allow him to submit improper bills. Instead of picking up the phone and simply advising our client of his errors, they continued to allow him to bill and be paid over $16 million in taxpayer funds! Our theory was that the Government simply wanted to build their case against our clients by allowing him to continue to bill.
Medicare, through its private insurance company "contractors, has a duty to educate providers. Medicare regulations are complex and change monthly. Medicare has set up "call in centers" which allow providers to call and ask questions concering billing, coverage, etc. However, if you use these "call in centers" take their answers with a grain of salt. A GAO study (Government Accounting Office) showed that out of 300 calls made to the "call in centers" only 4 percent were answered correctly! So what if you are a provider who calls in, gets incorrect answers, and then submits a bill to Medicare based on this information which proves to be wrong? You will have a difficult time proving the communication with the "call in center" unless you document the conversation in writing.
If you do decide to call Medicare for education on any issue, you should follow up with them by sending a letter via certified mail confirming your conversation. Document everything!
Don't let the government turn a mistake into a crime.
Charles R. "Chuck" Mullins has experience dealing with Health Care Fraud issues. To learn more about Chuck, go to his website.