Friday, October 3, 2014

Fraud Accusations for Delays in Refunding Medicaid Overpayments

Dianne De La Mare

In a recent federal action, the US Department of Justice (DOJ) has intervened in a False Claims Act (FCA) whistleblower (qui tam) suit in the US District Court for the Southern District of New York. The suit, originally filed by a former hospital employee, alleges that the hospital group submitted hundreds of improper claims to Medicaid in 2009 and 2010 through a computer problem that improperly coded private Medicaid Managed Care Organization (MCO) claims for submission to Medicaid for additional reimbursement. Under the Medicaid reimbursement laws, traditional Medicaid excludes providers paid by private MCO plans from any additional payments through Medicaid.

Despite being made aware of the problem in late 2010 by the former employee, the hospital group failed to take appropriate steps to repay the claims, and in fact dragged out full repayment to the government for over two years. Under the ACA, “overpayment” is defined as any funds that a person receives or retains under the Medicare or Medicaid programs that he/she is not entitled. Retaining an identified overpayment is an “obligation” under the FCA, which means that the government can pursue civil penalties against anyone who retains those overpayments as “reverse false claims.” The complaint requests the maximum penalty under the FCA of $11,000 for every improperly retained overpayment, in addition to treble damages. All totaled, a complete victory by the DOJ could result in $30million in fines for the hospital group.

AHCA will continue to monitor this important litigation. (US Ex Rel Kane v Continuum Health Partners).

No comments:

Post a Comment