Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

May 15: Week That Was in Healthcare Fraud and Malpractice

- Here is a general roundup of the past week’s developments in healthcare fraud and malpractice, as reported by the Department of Justice and the Office of Inspector General. The crimes reported below result in multiple millions of dollars in healthcare fraud and the possibility of extensive prison time.

Healthcare Fraud and Malpractice

NCI awarded $52M fraud, waste, abuse prevention contract  

This week, NCI, Inc. was awarded a $51.9 million cost-plus-fixed fee contract for fraud, waste, and abuse prevention to support the National Supplier Clearinghouse (NSC) for the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid (CMS). NCI utilizes advanced technology to amend and advance the NSC program.

“NCI’s solution applies advanced technology to adapt and improve the NSC program to aid in the prevention of fraud, waste and abuse, while enabling rapid enrollment of qualified durable equipment suppliers to support the needs of Medicare beneficiaries nationwide,” confirms a BusinessWire press release.

Brian J. Clark, President of NCI, states the award represents important innovative work as an imperative NCI milestone. “Our wholly-owned subsidiary, AdvanceMed, has a long history of supporting CMS, giving us in-depth durable medical equipment policy expertise and an excellent track record performing fraud investigations,” says Clark. “This, coupled with NCI’s technological capabilities and innovative methodologies, helped us bring a strong solution and unique capability set to the needs of this program.”

$13M FL Medicare fraud scheme leads to a decade in prison

Alexander Lara, owner and operator of Longcare Home Health Corporation, pleaded guilty this week to one count of conspiracy to commit healthcare fraud. Lara was sentenced to 10 years in prison for leading a $13 million Medicare fraud scheme in association with kickbacks and bribery across southern Florida.

According to the Department of Justice’s report, Lara’s company fraudulently billed the Medicare program for costly physical therapy and home healthcare services deemed medically unnecessary. Some services that were billed were never provided. Medicare paid Longcare Home Health Corporation over $13.5 million from 2009 to 2014 for fraudulent claims, confirm court documents.

Lara admitted to paying patient recruiters and Medicare beneficiaries kickbacks and bribes in exchange for referrals. Additionally, Lara confirmed illegally paying physicians’ offices and healthcare clinics in exchange for fraudulent home health prescriptions for services either deemed medically unnecessary or nonexistent. Lara was ordered to pay over $13.5 million in restitution.

Physicians' Medicare provider numbers stolen

Sharon Monroe, owner of the Louisiana-based intensive outpatient program company was sentenced to 27 months in prison for charging Medicare for services that were never actually rendered. Monroe, owner of Monroe Medical Management, LLC, was sentenced for one count of healthcare fraud, one count of wire fraud, and three years of supervised release. Monroe will pay nearly $1 million in restitution.

In addition to filing claims for psychotherapy services that were not rendered, Monroe also used physicians' Medicare provider numbers to submit claims. These physicians were not aware of such actions, confirms the Department of Justice. Monroe also claimed her employees, some of whom were medically unqualified, rendered services for more than 24 hours a day. Some of these services were erroneously reported as being performed within medical offices.

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