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Ambiguity Surrounding MAO Claim Denials Hampers Fraud Detection

Investigation included 55 million records from 2019. Adjustment codes are sometimes too vague to clearly identify whether a Medicare Advantage Organization (MAO) denied payment for a service, the Office of Inspector General (OIG) concluded in a February 2023 Issue Brief. Without specifics about the services for which the MAO is denying payment, the OIG cannot […]

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AAPC Knowledge Center

OIG Reports on Home Health and Hospice Fraud and Abuse

The Office of Inspector General (OIG) offers its fraud and abuse perspective for home health and hospice in its latest Semiannual Report to Congress — and it’s not a warm, fuzzy hug. For home health, the OIG lists two high-profile fraud cases. Case No. 1: SHC Home Health Services of Florida and its related entities […]

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AAPC Knowledge Center

Owner Of Shuttered Hospice Pleads Guilty To COVID Aid Fraud

Case is just one of many in an alleged $ 8 billion pandemic fraud spree, according to DOJ. The feds are keeping an ever-sharper eye out for fraud related to COVID-19 relief funds, and a California hospice owner was one of the fraudsters spotted. Gurgen Israyelyan owned Saint Christopher Hospice Inc. in North Hollywood, which closed […]

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AAPC Knowledge Center

OIG Releases Medicaid Fraud Annual Report

Medicaid Fraud Control Units recovered $ 1.7 billion in fiscal year 2021. Reducing Medicaid fraud is a top priority for the U.S. Department of Health and Human Services Office of Inspector General (OIG). Every year Medicaid Fraud Control Units (MFCUs) in all 50 states investigate and prosecute Medicaid provider fraud and patient abuse or neglect under […]

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AAPC Knowledge Center

Feds and U.S. Attorneys Continue to Crack Down on Telemedicine Fraud

Medical practitioners in Michigan are held responsible for their role in Medicare fraud scheme. On Aug. 24, U.S. Attorney Andrew B. Birge announced criminal and civil enforcement actions against four Michigan medical practitioners for their role in perpetuating a telemedicine scheme to defraud Medicare. The practitioners signed off on illegitimate orders for medical braces and […]

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AAPC Knowledge Center

The Evolution of Fraud Liability

Nothing stays the same, including the way the feds interpret the law. The False Claims Act (FCA) has become the government’s fraud enforcement vehicle of choice, and the changes to the FCA under the Fraud Enforcement Recovery Act of 2009 (FERA) and the Affordable Care Act (ACA) have enhanced the Department of Justice’s (DOJ’s) enforcement […]

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AAPC Knowledge Center

Improper Billing of P-Stim Devices Leads to More Fraud Settlements

Two chiropractic practices agree to pay over $ 800,000 to resolve liability for the alleged improper billing of P-Stim devices. In the latest case of improper billing of P-Stim electro-acupuncture devices, two integrated chiropractic practices and their owners have agreed to pay $ 805,978 to resolve liability under the False Claims Act. This case comes on the […]

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AAPC Knowledge Center

Guam Ambulance Company Owners Sentenced to Prison for Their Roles in Medicare Ambulance Fraud Scheme

Guam Ambulance Company Owners Sentenced to Prison for Their Roles in Medicare Ambulance Fraud Scheme.

Two owners of Guam Medical Transport (GMT) were sentenced to prison terms today for their roles in a health care fraud and money laundering scheme that resulted in a loss to the United States of approximately $ 10.8 million, one of the largest single Medicare ambulance fraud cases ever prosecuted by the Justice Department.

Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Shawn N. Anderson of the Districts of Guam and the Northern Mariana Islands, Special Agent in Charge Eli S. Miranda of the FBI’s Honolulu Field Office, Special Agent in Charge Justin Campbell of IRS Criminal Investigation (IRS-CI) Seattle Field Office and Special Agent in Charge Timothy DeFrancesca of the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) Los Angeles Regional Office made the announcement.

According to their admissions at the plea hearing, from approximately March 11, 2010, to approximately March 21, 2014, the defendants engaged in a conspiracy to defraud Medicare and TRICARE by submitting claims for reimbursement for medically unnecessary ambulance services that GMT provided to patients with ESRD.

As part of the scheme, the defendants directed GMT employees to remove from internal documents references to GMT patients’ ability to walk because they knew that Medicare and TRICARE would not provide reimbursement for the patients.

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The Coding Network

Tallahassee Health Care Provider Arrested for Medicaid Fraud

Tallahassee Health Care Provider Arrested for Medicaid Fraud

A Tallahassee health care provider has been arrested for billing the Florida Medicaid Program around $ 50,000 for fraudulent medical services, according to Florida Attorney General Ashley Moody.

Rodney Burt, 57, was arrested Friday on Medicaid fraud charges after he billed the state’s Medicaid program for phony services from May 2016 to November 2019, the press release said.

“That is why my Medicaid Fraud Control Unit attorneys and investigators aggressively chase down leads and uncover abuses in this taxpayer funded health care program to ensure those who would aim to rip off taxpayers are stopped and brought to justice.”

The investigation revealed he was assigning inaccurate billing codes to claims he submitted to the Florida Medicaid Program to increase reimbursements, which fraud investigators call “upcoding.” Burt’s charge of Medicaid provider fraud of $ 50,000 or more is a first-degree felony.

The post Tallahassee Health Care Provider Arrested for Medicaid Fraud appeared first on The Coding Network.

The Coding Network

Biotech Executive Charged in COVID-19 Test Fraud Case

As if the coronavirus pandemic wasn’t bad enough as it is, fraudsters in the healthcare industry are manipulating it to further their wealth. The ongoing public health crisis has spawned a rash of fraudulent schemes, making COVID-19 fraud investigations a top priority for government agencies determined to root out fraud and corruption being committed against […]

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AAPC Knowledge Center