The U.S. Department of Justice (DOJ) got a new arrow in its quiver, allowing it to exponentially increase its ability to prosecute certain types of healthcare fraud.
While the False Claims Act (FCA), with its qui tam provisions empowering whistleblowers to initiate lawsuits, will remain DOJ’s primary tool to prosecute fraud perpetrated against federally funded health insurance programs like Medicare, Medicaid, Tricare, and the Indian Health Service, a new whistleblower program – the DOJ Corporate Whistleblower Awards Pilot Program – seeks to pay whistleblowers for information about federal healthcare offenses and related crimes involving fraud against private health insurers, patients, investors, and other non-governmental entities.
According to Deputy Attorney General Lisa Monaco, one of the main purposes of the Pilot Program is to close gaps left in the existing group of whistleblower reward programs, noting that while these programs (like those falling under the umbrella of the FCA) have proven indispensable, “they resemble a patchwork quilt that doesn’t cover the whole bed.” In enumerating the subject areas where DOJ is soliciting whistleblower information under the new program, DOJ identifies categories of misconduct related to healthcare: federal offenses and related crimes involving private healthcare benefit programs, fraud against patients and investors in the healthcare industry, and a catch-all provision, seeking information about other federal violations related to healthcare not covered by the FCA. As regular RACmonitor readers and Monitor Mondays listeners know, the False Claims Act only applies when the federal government is the defrauded party. However, if an unscrupulous hospital is overbilling a commercial insurer, or a greedy dentist is overcharging their patients, the law does not apply. That’s where the new program seeks to fill gaps.
To minimize potential overlap between qui tam cases under the FCA and criminal whistleblowing under the new program, DOJ notes in its guidance that its focus is on healthcare matters where the overwhelming majority of claims and fraud loss involved non-governmental payors and other victims.
To be eligible for an award, the whistleblower’s information must lead to successful forfeiture exceeding $1 million in net profits, in connection with a prosecution, corporate criminal resolution, or civil forfeiture action related to the corporate misconduct. Without a successful forfeiture, a whistleblower will not be able to receive an award. Under the Pilot Program, a whistleblower may receive up to 30 percent of the first $100 million in net forfeitures, plus up to 5 percent of net forfeitures between $100 and $500 million.
In creating this program, DOJ appears to have been inspired in part by the existing whistleblower reward programs within the departments of insurance for the states of California and Illinois. These programs reward whistleblowers for filing cases where commercial health insurance fraud is at issue. California and Illinois have recovered tens of millions of dollars as a result of these programs, and DOJ seeks to do the same. By focusing on fraud against private insurance programs, DOJ is significantly expanding its healthcare enforcement efforts, and in so doing, raising the stakes for companies that fail to heed whistleblowers’ internal warnings about fraud against private insurers, patients, and other non-governmental victims.
In another noteworthy development in the whistleblower world, thanks to Dr. Ronald Hirsch, I also want to discuss a FCA case launched by a whistleblower in federal district court in New Jersey against Homecare Homebase, LLC, the developer of software for home-based care, which joins a number of recent cases finding that software providers can be liable for submitting false claims based on their software design. In a recent court decision in the case United States ex rel. Schieber v. Holy Redeemer Healthcare System, Inc., a New Jersey district court judge declined to dismiss the whistleblower’s qui tam case, holding that software billing company Homecare Homebase could be liable for causing the submission of false claims to the Centers for Medicare & Medicaid Services (CMS) by allegedly intentionally designing software that prompted its home health provider users to upcode the number of necessary therapy treatments, thereby increasing their Medicare reimbursements.
According to whistleblower Mark Scheiber, a physical therapist and former employee of Holy Redeemer Healthcare System, a user of Homecare Homebase’s software, Homecare Homebase caused home health providers like himself to upcode service claims because it automatically and repeatedly prompted the provider to select a higher number of necessary visits, even after they already had input the number of necessary visits into the software. The court found that the complaint properly alleged that a software company can be liable if its conduct was a substantial factor in the submission of false claims, and that allegedly intentionally designing an application to encourage upcoding was sufficient to satisfy the “substantial factor” causation standard.
For healthcare tech companies, the message is becoming increasingly clear: be aware that features built into your software code can readily cross the line from education into fraud.
Well, one of our clients recently got me really excited. They received a denial of an inpatient admission from a well-known Medicare Advantage (MA) plan
As my colleague Matthew Albright reported a few weeks ago, the upcoming election may have slightly less of an impact on the business of healthcare
Please log in to your account to comment on this article.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.
ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.
Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.
During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
