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

Policy & Regulation News

The Week That Was in Healthcare Legality

By Ryan Mcaskill

A recap of high-profile charges, convictions and sentencing involving healthcare legality ending the week of January 9, 2015.

- Healthcare is a multi-billion dollar industry. It is also a hot bed for fraud because of the large sums available. Here is a roundup of some of the more interesting legal dealings in the U.S. from the past week.

Government joins two Medicare fraud lawsuits

In 2011 and 2014, Dr. Asad Qamar was sued by two whistleblowers – a former employee and the director of a medical management company – in separate lawsuits. It was alleged that the Florida cardiologist padded bills by “upcoding,” waived copays and deductibles so patients would agree to costly tests and services and performed unnecessary procedures. This allegedly happened thousands of times to the price tag of tens of millions of dollars.

The original lawsuits were filed under the False Claims Act, which allows citizens to suit in the name of the government when they believe that someone falsely received government money.

This week, the Justice Department got involved in the case against the top Medicare biller for cardiology in the nation.

The interest from the government started last year when information was released showing how much Medicare programs paid to each physicians. Dr. Qamar and his practice – Institute of Cardiovascular Excellence – billed for $18 million in 2012. The second highest cardiologist had only billed $4.5 million during the same time frame.

“Physicians should make medical decisions on the basis of their patients’ needs,” A. Lee Bentley III, U.S. attorney for the Middle District of Florida, said in a press release. “Performing medically unnecessary procedures solely to line a physician’s pockets strains our nation’s healthcare system, and can also jeopardize the health and safety of patients.”

Dr. Qamar has released a video addressing these accusation and flatly denies them.

Judge rules Medicare certification protected during bankruptcy

Bayou Shores SNF LLC was cited by inspectors for endangering residents in 2013 and 2014. This caused the Centers for Medicare and Medicaid Services to revoke the nursing home’s participation in the government health program. While this action was happening, Bayou Shores declared Chapter 11 bankruptcy. This created an issue, because Chapter 11 prevents the changing of any contracts.

According to Law360, a court case ensued and it was ruled that the government cannot cut off reimbursements to a nursing home that entered bankruptcy while appealing the termination of a certification.

“Although [CMS] gave the debtor notice it was terminating its Medicare provider agreement prepetition, that termination was not complete and irreversible until the appeals process was complete. And the appeals process was not completed prepetition,” Judge Michael Williamson said, according to Law360. “Because the debtor’s Medicare and Medicaid provider agreements remain in effect, the court concludes the debtor’s plan is feasible and should be confirmed.”

The government is appealing the decision. One lawyer – Judy Waltz of Foley and Lardner – is not associated with the case but told the news source that the ruling is “a nightmare.”

EMS accused of ‘inappropriately billing’

The Elks Rapids EMS has been accused of improperly billing patients for transports in an ambulance. The issues stems from the fact that the ambulances are licensed Advanced Life Support vehicles. This means that in order to bill, the ambulance is required to have a paramedic on board. However, it was discovered that in 33 cases, only two basic EMTs were present. This lead to $20,000 in fraudulent claims.

Christine Keenan, a former administrator at the Elks Rapids service told EMS1 that the company has an exemption. She also mentioned that the company is being kept in the dark and has not not seen the paperwork.



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