Hospitals & Health Systems

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Evaluation and management (E/M) services have been called “the core” of healthcare billing.[1] E/M is a catch-all claim, allowing medical professionals to bill for diagnosing or treating nearly any illness or injury. E/M is also divided into fairly subjective levels depending on complexity, and the differences between levels is often merely a difference of opinion. While the DOJ has brought cases based on disputes over E/M services before, those cases are typically civil and part of a more complex upcoding or unbundling scheme.[2] This is because nearly everything involving some effort expended by a physician could arguably justify that physician believing the E/M service was proper, and therefore criminal cases requiring scienter evidence that proves the case beyond a reasonable doubt are incredibly rare.

Yet one of those rare cases went to trial this month.…

Continue Reading Physician Loses Rare Criminal E/M Fraud Trial

On June 14, 2023, a federal jury found that a Georgia physician knowingly violated the False Claims Act following a two-week trial on allegations that he made false claims to the Medicare Program. Now, despite just $1.1 million in improper payments stemming from false claims, a federal court is likely to impose a judgment that exceeds $27 million after adding statutory per-claim penalties and trebling the amount determined by the jury to be false.…

Continue Reading Georgia Physician Awaits $27+ Million Judgment Following False Claims Act Trial Loss

Cosmetic surgeries are on the rise. One study of cosmetic surgery data found that body procedures like tummy tucks, buttock augmentation, and liposuction increased by 63 percent from 2020 to 2021.[1] Facelifts were up 54 percent.[2] And breast procedures were up 48 percent.[3] According to that study, Americans spent over $14.6 billion on aesthetic procedures in 2021 with surgical revenues increasing by 63 percent.[4]…

Continue Reading Justice Department Sues Iowa Surgeon Under False Claims Act for Masking Non-Covered Cosmetic Procedures as Covered Surgeries

On February 27, 2023, a jury in Minnesota federal court rendered a verdict in favor of the United States and against a surgical product distributor following a False Claims Act jury trial that lasted six weeks.[1] The jury identified $43 million in Medicare payments flowing from 64,575 kickback-procured claims.…

Continue Reading Trial Lost, $400+ Million Liability Looming: Quick Takeaways From a Recent False Claims Act Jury Trial

In the world of qui tams, it is usually the whistleblower pushing cases to trial. But on February 23, 2023, a federal judge in West Virginia set down for trial a hospital’s case against a whistleblower. Now, in a trial set for late March 2023, a jury is set to determine whether a whistleblower and the general counsel for a competing health system engaged in malicious prosecution and tortious interference by filing a qui tam against a West Virginia hospital.…

Continue Reading Hospital Turns Tables on Whistleblower: Federal Judge Sends Hospital’s Case Against Whistleblower to Trial

Stories can be powerful tools. Stories can create a sense of connection and have the power to shape the lives of both the storyteller and the listener. Stories also make ideas and experiences relatable and can encourage exploration or action. And it was the stories I heard from members of AHLA’s Women’s Leadership Council that inspired me to write this column as a reminder of the incredible impact of AHLA’s educational mission supported by AHLA’s philanthropic initiatives.…

Continue Reading Women’s Network—Storytelling: AHLA’s Educational and Philanthropic Mission

Executive Order GA-40

On July 26, 2022, Judge Jeremy Kernodle of the Eastern District of Texas affirmed that certain parts of the Interim Final Rule Part II implementing the No Surprises Act (the Act) were invalid. This ruling is nearly identical to Judge Kernodle’s February decision in Texas Medical Association & Corley v. US Dept. of Health and Human Services. This decision vacated a portion of the Interim Final Rule that required arbitrators to give more weight to the out-of-network rate, including what is called the Qualified Payment Amount (QPA), over other permissible factors. The rule’s requirement ultimately contradicted the Act’s direction that arbitrators consider various factors, and not weight any one more heavily than another.
Continue Reading Eastern District of Texas Invalidates Parts of Implementing the No Surprises Act

Healthcare Providers

Workplace violence has become a hot topic in today’s discourse; however, workplace violence is not just headline fodder for media outlets. The trend is well-documented and especially felt by the healthcare industry which continues to experience the brunt after the onslaught of COVID-19. In 2018, 73% of all nonfatal workplace violence incidents involved healthcare workers. A late 2020 survey reported that 20% of nurses reported they were facing an increase in workplace violence after the COVID-19 pandemic began. Another study reported a 14.6% increase in workplace violence at New Jersey hospitals over the prior three years.
Continue Reading Code Blue! — Violence in the Workplace

Health insurance aid cardiogram care chain check

As the health care industry shifts from fee-for-service to value-based arrangements, providers are facing a lot of challenges. A provider’s relationship with payers is often strained by the new business model, and a provider’s ability to collaborate with payers has never been more important.

On this episode of Value-Based Care Insights, host Daniel J. Marino…

Hospice Insights

When confronted with a complaint, allegation or event that implicates a potential Medicare overpayment, hospices have an affirmative duty under the federal 60-day repayment rule to conduct an investigation and refund any overpayment. In this episode, Husch Blackwell’s Meg Pekarske and Andrew Brenton share tips and tools for conducting internal investigations and determining when an…