Bloomberg BNA Releases New Health Care Fraud Report

Bloomberg BNA released its Health Care Fraud Report detailing the healthcare industry's most recent enforcement actions on fraud, waste, and abuse. In its most recent newsletter, Bloomberg BNA highlighted the following three cases:

N.Y. Medicaid Overpayment Lawsuit on 60-Day Rule Survives

"A federal government lawsuit against three hospitals and managed care organization HealthFirst Inc. will move forward after a federal district court in New York rules there was sufficient evidence that the defendants knowingly avoided an obligation to return Medicaid overpayments past a 60-day repayment deadline (United States ex rel. Kane v. Healthfirst, Inc., 2015 BL 249012, S.D.N.Y., No. 1:11-cv-02325-ER, 8/3/15). The U.S. District Court for the Southern District of New York holds that the allegations sufficiently show the defendants triggered the 60-day repayment requirement, first introduced as part of the Affordable Care Act, when they took no further actions to investigate after an employee identified as many as 900 possible Medicaid overpayments and was subsequently fired four days later. The court mentions the defendants' purposeful inaction on the potential Medicaid overpayments until served with a government civil investigative demand multiple times in determining there was sufficient evidence to deny the defendants' motion to dismiss the action."

DOJ Cites ‘First of Its Kind’ Settlement on Overpayments

"A home health-care provider agrees to pay $6.88 million to resolve allegations it failed to refund overpayments from government programs, in what the Department of Justice describes as a "first of its kind" settlement (United States ex rel. Odumosu v. Pediatric Servs. of Am. Healthcare, N.D. Ga., No. 1:11-cv-1007, 8/3/15; United States ex rel. McCray v. Pediatric Servs. of Am., S.D. Ga., No. 4:13-cv-127, 8/3/15). Pediatric Services of America Healthcare and affiliated corporations (PSA) plus PSA's former owner, Portfolio Logic LLC, reach the joint settlement in two separate whistle-blower cases in the U.S. District Courts for Georgia's northern and southern districts, in which the U.S. and multiple states intervened. The U.S. claims PSA, based in Atlanta, failed to refund overpayments from TRICARE and the Medicaid programs of 20 states including California, Florida, Georgia, Illinois, New York and Texas between 2007 and 2013, according to the settlement agreement."

Medicare Plans Return $1.5 Billion in Overpayments

"Medicare Advantage plans return $1.5 billion in overpayments made for payment years 2006-2013, largely due to a risk adjustment audit program, the acting head of the Medicare agency tells the Senate Judiciary Committee chairman. The Centers for Medicare & Medicaid Services "has worked to reduce improper payments associated with inaccurate Medicare Advantage diagnosis data through, among other means, the risk adjustment data validation (RADV) audit initiative," acting CMS Administrator Andrew M. Slavitt says in a letter to Senate Judiciary Committee Chairman Charles E. Grassley (R-Iowa). The ACA established RADV, a program in which audited plans must submit medical records to back up the diagnosis data they had submitted to receive payments for enrollees."

Read the full newsletter and sign-up for the Bloomberg BNA Health Care Fraud Report at their website.