Saturday, May 21, 2022

Hospital, Top Surgeon Accused of Medicare and Medicaid Fraud

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Medicare and Medicaid Fraud

Medicare and Medicaid fraud means a medical provider like doctor, dentist, hospital, clinic care provider, or nursing home – makes a dishonest reimbursement claim. The most popular types of fraud include billing for unnecessary procedures or procedures that are never carrying out, for unnecessary medical tests or tests never executed; or for unneeded stuff.

medicare and medicaid fraud

What is Medicare and Medicaid fraud?

Medicare and Medicaid fraud refers to unlawful work getting biasedly high payments from government-funded medical care programs.

Medicare or Medicaid fraud cases can file to anyone who directly or indirectly causes fraud in the medical care programs. 

Medicare and Medicaid frauds also include a copy in state-administered medical care programs, based on federal matching money, and because most states have now accepted local versions of the False Claims Act.

Medicare or Medicaid Fraud breaks the False Claims Act. The qui tam law provisions of the False Claims Act allow persons and organizations with proof of Medicare and Medicaid Fraud against federal programs or agreements to prosecute the offender on behalf of the United States government. 

In qui tam actions, the government has the right to negotiate and join the effort. If the government rejects, the private complainant may continue on his own. Most Medicare or Medicaid False Claims Act cases also include claims under state qui tam laws modeled on the federal False Claims Act.

The Medicaid Fraud Control Units (MFCUs) work in 49 states and the District of Columbia to layout inquiries and faults related to possible fraud.

Most MFCUs work as part of the Attorney General’s office in that state and should be self-sufficient and independent from the state’s Medicaid office.

What actions are considered Medicare and Medicaid fraud?

There are many types of Medicare and Medicaid fraud. Common examples include:

  • Billing Medicare and Medicaid for services not provided.
  • Billing for services provided to unsuitable persons.
  • Damaged or illegal pricing of drugs.
  • Failure to observe with “best pricing” in the Medicaid program.
  • Failure to properly enroll qualified patients in a Medicaid-sponsored program.
  • Nursing home mistreats and mistreats patients.
  • Unlawful or unethical marketing of drugs.
  • Cheating at pharmacies.
  • “Off label” marketing of drugs.
  • Paying kickbacks to have doctors, hospitals, or other people prescribe certain drugs or otherwise bill Medicare and Medicaid.
  • Bribe to take the business.
  • Bribe to get prescriptions.
  • Perform irrelevant medical treatments.
  • Improper referrals or self-dealing.
  • Present to the federal government a false or dishonest Medicare and Medicaid claim for payment.
  • Purposely using a false record or statement to get a Medicare or Medicaid claim paid by the federal government.
  • Cooperate with others to get a false or fraudulent Medicare or Medicaid to claim paid by the federal government.
  • Knowingly using a false record or statement to cover, avoid, or minimize a responsibility to pay money or transmit property to the federal government.
  • Performing irrelevant tests or giving wrong guidelines, which is known as ping-ponging.
  • Charge separately for services that are usually charging at a package rate, known as unbundling.
  • Give benefits to which the patients who receive them are not allowing, using fraud, or not correctly reporting income or other financial details.
  • Make repayments to illegally completed claims.

The Difficulties of Working Medicare and Medicaid Fraud

Medicare and Medicaid fraud is a multibillion-dollar exhaust on a system that is already costly to maintain. The departments that look after these programs have internal staff members observing activities for signs of fraud. In addition, some external auditors are responsible for evaluating suspicious claim patterns.

To help prevent fraud related to recognize theft, Medicare carried out a new program in 2018. Medicare associates started to receive new ID cards with a Medicare Number rather than the participant’s Social Security number.

Identifying and preventing fraud is an essential factor for the people and departments that watch these critical programs. In addition, the wasted funds lost to fraud and other illegal strategies represent resources that can use to support participants who need support.

Below are the best two examples for talking about surgeons criticized of Medicare and Medicaid fraud.

The complaint is about the University of Pittsburgh Medical Center and the head of its neurological surgery department for falsely billing Medicare and Medicaid for operations.

The complaint is about James Luketich. He is doing multiple complex surgeries simultaneously by going alternating between patients. As a result, he does not participate in critical surgeries while keeping patients under unnecessary anesthesia.

The government claims Luketich and the University of Pittsburgh Medical Center broke the rules and regulations that prevent physicians like Luketich, who make teaching services within a medical school, from billing federal health insurance programs for such surgeries. It also alleges that the practice harmed patients.

The government claimed that Luketich’s workouts have severely harmed patients by continuing their surgeries and time under anesthesia, increasing the risk of complications.

Anyway, according to the complaint, Luketich proceeded to schedule and conduct concurrent operations.

Luketich is one of UPMC’s most significant sources of income, the government said, taking in tens of millions of dollars per year. As a result, it is exploring unspecified financial losses.

Here is the second example.

Dr. Vasso Godiali is a blood vessel surgeon in Michigan who composed a $65 million medical care fraud.

Federal prosecutors charged Godiali with submitting false claims for placing stents in dialysis patients and treating arterial blood clots. The surgeon also allegedly inflated and submitted false claims to Medicare, Medicaid, Blue Cross, and Blue Shield of Michigan, ultimately driving up healthcare costs and wasting taxpayer money.

He supposedly cleaned the money through six companies and used the interests to pay estate taxes on his Houghton Lake, Michigan house.

The federal district attorney also filed a related civil claim inquiring $40 million from accounts managed by Godiali correlated to four real estate purchases.

A medical care fraud charge can bring ten years of prison time and a supreme penalty of $250,000 on any two counts. If convicted of money laundering, Godiali would serve a maximum sentence of 20 years and be fined up to twice the $49 million he allegedly laundered. He faces five counts.

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Nora R. Tripp
I am a self-motivated medical billing and coding professional with over 15 years of experience in health operations management, billing, and coding. Expertise in ICD-9 and ICD-10 coding, as well as CPT and HCPCS coding. Expertise in evaluating and validating patient information, diagnoses, and billing data. I demonstrated leadership abilities that allow for the processing of large amounts of patient information in order to satisfy revenue generation targets.

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