A $22 million U.S. Department of Justice (DOJ) settlement with a university hospital that allegedly mixed up billing from its facility and provider departments underlines the importance of keeping straight what gets sent to CMS, and by whom. …
Beware ‘highly technical rules’
“The takeaway here really is the continued focus, for False Claims Act enforcement purposes, on the examination of business relationships for compliance with highly technical rules and regulations — ones which have absolutely nothing to do with the quality or necessity of the medical care being provided to patients,” says George Breen, member of the Epstein Becker Green law firm in Washington, D.C., and chair of its national health care and life sciences steering committee.
Breen notes the allegation involving pre-transplant laboratory testing, in which “the claim was not that the provider wasn’t entitled to reimbursement, or that the service was not necessary, it was that the reimbursement was sought at an inappropriate level.
“There was no allegation with respect to this particular claim that the services were unnecessary, lacked medical quality or that there was any resulting patient harm,” Breen adds. “It was, simply, whether the amount reimbursed exceeded what the government should have to pay.”
The message to providers is “the need to ensure a robust examination of such internal relationships given the government’s continued interest in examining them for compliance with billing rules, and under the lens of the anti-kickback statute and the Stark Law,” Breen says.
“The lesson is to ensure that such business relationships and procedures are vetted from the outset to ensure that there are no concerns with the propriety or manner in which those services are billed.”