News: Medicare 'sting' charges more than 100 defendants including doctors and nurses

March 3, 2011

The Department of Health and Human Services (HHS) called it the largest healthcare fraud sting in history. On February 17, the Medicare Fraud Strike Force charged 111 defendants in nine cities, including doctors, nurses, healthcare company owners and executives, and others, for alleged participation in Medicare fraud schemes.The money these individuals allegedly bilked from the government in false billing is estimated at more than $225 million, according to an HHS release.

According to a report from the Associated Press, the charges allege that a Detroit podiatrist performed partial toenail removals that amounted to little more than clipping toenails and a Brooklyn proctologist billing $6.5 million for hemorrhoid removals never actually performed.

Although most of the services targeted by the Health Care Fraud Prevention and Enforcement Action Team (HEAT) were not associated with hospital inpatient conditions, and while these charges appear to represent clear instances of attempts to defraud the Medicare system, CDI staff understands how easy it can be for physicians to run afoul of the documentation requirements associated with the medical necessity of a given procedure.

One need look no further than the recent spate of recovery audit contractor (RAC) target issues:

Connolly Healthcare, the RAC for Region C, added 37 new issues —12 for DRG validation claims and 24 for medical necessity claims
DCS Healthcare added three new issues for medical necessity claims to its CMS-approved list
CGI, the RAC for Region B, added five new issues for medical necessity claims to its CMS-approved list

Compliance was a key discussion point at the 2010 ACDIS Annual Conference. A number of speakers suggested that CDI specialists who lead physicians to document diagnoses or focus solely on DRG optimization may be putting themselves at risk with RAC contractors and/or accusations of fraud.

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