Brian Roark, attorney at Bass, Berry & Sims, is extensively quoted regarding Medicare billing fraud for Healthcare Risk Management. The article, titled "Avoid Being Drawn Into Billing Fraud," discussing seven recent cases of fraudulent Medicare billing totaling $26 million in unneeded or undelivered medical equipment, was published on January 1, 2010.
From the article:
Such brazen fraud likely would not go unnoticed by a risk manager if it originated within the organization, but it still is possible to get involved in these schemes unless you take the right precautions, says Brian D. Roark, JD, an attorney with the law firm of Bass, Berry and Sims in Nashville, TN.
"On the criminal side, the federal government is devoting significant resources to prosecuting street-level fraud cases where Medicare or Medicaid is billed for services not rendered, such as individuals setting up fake medical supply companies," he says. "Additionally, the government is employing increasingly sophisticated investigative techniques to spot fraud, such as using data mining to find aberrations in claims-filing patterns and using prepayment claims editing to compare new claims to previous claims and detect fraud in almost real time. Some of the primary areas of focus by the government are on durable medical equipment [DME], prosthetics, orthotics and supplies, home health agencies, and infusion therapy."
Roark also points out that the Fraud Enforcement and Recovery Act of 2009 (FERA) made significant amendments to the False Claims Act (FCA), which is the primary civil enforcement tool for health care fraud. The result of the FERA amendments was to expand liability under the FCA, take away certain defenses previously available to defendants, make it easier for the government to share information with qui tam whistle-blower plaintiffs, and expand whistle-blower protections.
"The FERA amendments likely will increase the number of FCA lawsuits brought against health care providers," Roark says.
Roark says a key way to avoid involvement in such fraud is to make compliance the responsibility of the entire organization and provide mechanisms for employees to raise any compliance concerns.