Based on OIG enforcement action excerpts for the past week, tips for staying ahead in healthcare regulatory compliance efforts include:

  • If a patient walks to the ambulance and can be safely transported by means other than ambulance, it is likely that the ambulance service is not appropriately billed to Medicare. Rebutting scrutiny of such services is likely to be particularly difficult if the patient receives kickbacks.
  • Billing Medicare for services not ordered by physicians and not wanted by patients is particularly risky. It is also important to verify that services are only provided to living patients.
  • Regulators are likely to only have a sense of humor when naming enforcement operations. In Operation “Home Alone 3,” regulators did not find it amusing when personal assistant services were billed for patients during times when the patients were imprisoned, hospitalized, at work or dead. Also, admission of “having seen news reports of our crackdown on this type of fraud but [going] ahead and submit[ing] the false claims anyway” does not appear to create favorable sentiment with regulators.
  • Issuing or selling prescriptions or DME, home health and similar certifications to service providers is likely problematic, particularly if it is known that the prescriptions and certifications are fraudulent.
  • Combining two service lines subject to scrutiny, such as allergy testing and sleep studies, in one venture is not likely to reduce scrutiny. Risk is particularly great when services billed to Medicare are not performed or medically necessary and payments, a/k/a kickbacks, are made to recruiters for new patients.
  • The Federal Employees Health Benefit Program (FEHBP) may result in false claim liability even if it is not considered a federally-funded health plan for purposes of federal anti-kickback law.