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The following hospitals were recently sued by a federal prosecutor: Baptist Medical Center Downtown, Baptist Medical Center South, Baptist Medical Center Beaches, Baptist Medical Center Nassau, Memorial Hospital Jacksonville, Orange Park Medical Center, Specialty Hospital Memorial Health, Lake City Medical Center, and UF Health Jacksonville. For what did they come under fire? Did they submit fraudulent bills or cause bills to be submitted to Medicare inappropriately? Nope.

What is the issue?

The federal prosecutor is not going after them for what they did. He is going after them for the billings of the ambulance companies transporting patients to and from their facilities. The ambulance companies billed Medicare. The hospitals have decided to settle to avoid lengthy litigation and associated bad press. I wish they hadn’t settled, because it sends the wrong message.

I was lucky enough to help the Fire Department of New York after it was hit with a billing scandal related to ambulance services a number of years ago. I imagine that most people do not know that the FDNY was the largest submitter of ambulance claims in the country at that time (and still is, I believe). 

In order for Medicare to pay for an ambulance trip, the trip must be “medically necessary,” I learned, with the beneficiary’s medical condition such that other forms of transportation are medically contraindicated (meaning it just is not safe to send them any other way). 

If an attending physician at a hospital or any other hospital employee calls for an ambulance in the case of a transfer, could they possibly know that the ambulance provider is going to bill Medicare? I would argue not.

In 2009, the False Claims Act (FCA) redefined “claim” to mean “any request or demand, whether under a contract or otherwise, for money or property, and whether or not the United States has title to the money or property.” That is, a request or demand:

  1. Presented directly to the United States; or
  2. “To a contractor, grantee, or other recipient, if the money or property is to be spent or used on the government’s behalf.”

It seems in this case that the government is attempting make the argument that hospitals and nursing homes are somehow contractors or grantees of the ambulance companies billing for services, even if they are not billing the services. It’s more than just an issue of forcing hospitals and nursing homes to be responsible for billings they did not submit for services they did not provide; and it presents a slippery slope leading to other potential problems.

Let’s take an example. Say a hospital provides a list of local physicians to a patient to provide follow-up care after discharge. Some of the physicians are on staff, and some are just known to the hospital. Maybe the discharge planner just did a search on the Internet. The patient goes to one of the doctors. Unknown to the hospital, the physician has run into financial problems and has begun overbilling Medicare. A year later, the physician’s unusual billing practices hit the notice of a Zone Program Integrity Contractor. Under this new construction of the FCA, the U.S. Health and Human Services Department Office of Inspector General (HHS OIG) files suit against the hospital. 

How can I protect myself? It’s a good question.

Because it is my preference in life, my first stop is the use of big data. The Centers for Medicare & Medicaid Services (CMS) regularly publishes a list of all physicians in the country, sorted by specialty. Find out what doctors and other professionals practice in your area. Then get more information. The OIG exclusion database is a good place to start. Finally, then, there is communication. Make sure information about local providers gets to your finance department and your compliance officer. 

About the Author:

Timothy Powell, CPA, is an independent healthcare consultant who resides in Florida.

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Timothy Powell, CPA

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

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