GA Hospital Overcharges Medicare Beneficiaries, Pays $20M
By - The Medical Center of Central Georgia (MCCG), known as Medical Center, Navicent Health, the second largest hospital in Georgia, will pay $20 million for violating the False Claims Act, according to a report from the Office of Inspector General (OIG) and the Department of Health & Human Services (HHS).
The hospital billed Medicare for steeply priced inpatient services that should have been billed as much cheaper outpatient or observation services, according to reports. MCCG violated the False Claims Act by intentionally overcharging Medicare over the course of four years for inpatient admissions not deemed medically necessary. Such provided care should have been billed as more cost-effective outpatient or observation services, confirms OIG and HHS.
Charging the government for more expensive inpatient services when cheaper alternatives exist causes Medicare to pay a higher amount than needed, explains Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department’s Civil Division within OIG/HHS report. “This department will continue its work to stop abuses of the nation’s health care resources and to ensure patients receive the most appropriate care,” adds Mizer.
The consequence of such actions is severe financial harm to Medicare and the healthcare industry at large. “Overcharging the government for medical services wastes our country’s limited health care resources,” states Acting Attorney John Horn of the Northern District of Georgia. “When a provider inflates its billings, we will aggressively seek to recover the overcharges under the False Claims Act,” Horn adds.
MCCG will engage in major compliance efforts over the next five years via a corporate integrity agreement with HHS-OIG. Under such compliance efforts, there will be an extensive review to confirm accuracy of MCCG’s claims for services administered to Medicare beneficiaries.
Pointlessly admitting patients who should have been treated in an outpatient or observation setting, for the purpose of a hospital or hospital organization’s financial gain, wastes taxpayer dollars and destroys trust, confirms Special Agent in Charge, Derrick L. Jackson, of HHS-OIG. “Medicare beneficiaries must feel secure and know that the care selected for them is in their best interest, and not merely what will generate the most revenue for the facility,” adds Jackson.
Recovery efforts to combat healthcare fraud and malpractice are ongoing but effective. According to a PR Newswire release, the False Claims Act is twofold. It presents private citizens with insider knowledge of fraud, waste, and abuse to enact justice. Additionally, a winning case means the government can recover triple the defrauded amount. Successful whistleblowers can receive up to 30 percent of this amount. Last year, the government and states recovered over $6 billion on behalf of whistleblowers’ actions.
"It's all about incentivizing integrity," says Mike Bothwell, Partner at Bothwell Law Group, who helped settle a recent former $520,000 settlement with another Georgia-based hospital, Irwin County Hospital.
In the case of Irwin County hospital, allegations involved patient referral kickbacks and billing for imaging services that had been erroneously performed.
"Chiselers are always incentivized to cheat,” maintains Bothwell. “The False Claims Act sets things right by providing a countervailing incentive to do the right thing."
MCCG’s perspective is one of interpretation inquiries
Statements from MCCG allegedly contradict the aforementioned information.
Says Judy Ware to Albany Herald, Chief Compliance Officer with Navicent Health, “At all times, patients received medically necessary services, and the government did not claim otherwise.”
Confusion abounds. The statement from MCCG additionally explains many hospitals actively struggle to interpret whether a short hospital stay should be billed to Medicare as an inpatient or outpatient claim.
“It involves complex medical decisions on whether the patient is admitted as an inpatient or an outpatient,’’ Ware confirms. “We work with the physician to use their expertise.”
Future efforts to hinder similar investigations for overcharging Medicare beneficiaries are strongly in place. Says Dave Smith, Consultant at Kearny Street Consulting, gray areas in billing are commonplace and second-guessing a hospital’s decision is quite easy as the federal government continues to crack down on similar billing cases. “If it’s blatant, that’s something different,” Smith confirms.
Medicare and Medicaid fraud has Georgia on its mind. Hopefully, the end of such events are near to ensure authenticity and trust within the healthcare indsutry.
