Audit Claims? What A Novel Idea!


If hospitals defraud Medicare, could they also defraud private pay health plans too? Most plan sponsors don’t audit their health care claims either because they never have “so why start now?”, or they are prohibited from doing so through contracts of adhesion i.e, managed care contracts. 

Hospitals In 15 States To Pay $28M To Settle Medicare Fraud Case

The Justice Department alleged that 32 hospitals overbilled Medicare for procedures that could have been done on an outpatient basis. In other legal news, news outlets report on other claims-related fraud cases in Ohio, Maryland, Florida and Louisiana.

The Associated Press: Hospitals Pay $28M To Settle Allegations Involving Medicare
The U.S. Justice Department says 32 hospitals in 15 states have agreed to pay $28 million to settle allegations they admitted patients for certain procedures that could have been done on an outpatient basis, resulting in higher Medicare bills. (12/18)

The Arizona Republic: Banner Health, Other Hospitals Pay $28 Million In Medicare Overbilling Probe
The federal government said Friday that two Arizona hospitals are among 32 hospitals in 15 states that will pay more than $28 million to settle claims they overbilled Medicare for a spinal procedure. The two Arizona hospitals, Banner Boswell in Sun City and Banner Thunderbird in Glendale, agreed to pay nearly $2.7 million to settle claims. (Alltucker, 12/18)

The Cleveland Dispatch: Cleveland Clinic Agrees To Pay $1.74 Million To Settle False Medicare Claim Allegations
The Cleveland Clinic is among 32 hospitals in 15 states that have agreed to pay the federal government a total of more than $28 million to settle allegations that they submitted false Medicare claims for spinal fractures, the Justice Department announced Friday. (Eaton, 12/18)

The Associated Press: Maryland Firm To Pay $10M In False Claims Act Settlement
Federal officials say Maryland-based splint supplier Dynasplint Systems and its founder and president have agreed to pay more than $10 million to resolve allegations that they violated the False Claims Act. Dynasplint, founded by George Hepburn, was accused of mischarging Medicare for splints used by patients in Medicare-certified skilled nursing facilities. (12/18)

Tampa Bay Times: Five Tampa Bay Area Hospitals Settle Claims They Inflated Costs For Spinal Procedure
Five hospitals in the Tampa Bay region have agreed to settle allegations that they improperly increased their Medicare billings by frequently charging inpatient rates for a spinal procedure that can be performed less expensively on an outpatient basis, the U.S. Justice Department announced Friday. Topping the list was Citrus Memorial Health System in Inverness, which agreed to pay $2.6 million in fines. Tampa General Hospital will pay $2 million. And three hospitals affiliated with BayCare Health System in Clearwater — St. Joseph’s Hospital in Tampa, St. Anthony’s Hospital in St. Petersburg and Winter Haven Hospital — have agreed to pay a total of $1.5 million. (12/19)

The Fiscal Times: Billions In Medicare Fraud Still Rampant Despite Federal Crackdown
In the latest government blow against rampant Medicare fraud, two doctors and a registered nurse in New Orleans were given stiff prison sentences and millions of dollars in fines this week in federal court for their roles in a long-term $50 million scheme. The trio and a fourth defendant were convicted of submitting roughly 8,000 fraudulent Medicare claims over a six-year period for referring patients to Memorial Home Health Inc. and three other “sham companies” for “medically unnecessary” home health services and treatment, according to a federal indictment reported by The Times-Picayune. In many cases, the treatments were never rendered. (Pianin, 12/18)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.