Government cracks down on pharmacies, home health agencies, medical directors for medically unnecessary services

It’s no secret that in recent years the number of healthcare fraud investigations and prosecutions in the U.S. has rocketed. Clearly, the amount of taxpayer dollars being lost to fraud and abuse, coupled with the potential for big payoffs when fraud is detected, is a great motivator.

Every year that the government racks up successful prosecutions and greater recoveries means increased oversight of healthcare billing activities. This year, and likely into 2016, the focus has turned to those alleged to be billing for medically unnecessary services and procedures.

All one has to do is visit the U.S. Department of Justice’s website to see the number of providers being targeted. In November alone there were three actions taken relating to the provision of medically unnecessary services and/or procedures, two of them right here in South Florida.

Miami-Area Pharmacy Owner Sentenced to 42 Months in Prison for Role in $1.5 Million Medicare Part D Fraud Scheme

Home-Health Agency Owners and Director of Nursing Indicted in $13 Million Medicare Fraud Conspiracy

Medical Director and Three Therapists Sentenced for Their Roles in $63 Million Miami Health Care Fraud Scheme

While there are legitimate cases of fraud and abuse, some have come to question whether prosecutors are going so far as to criminalize a provider’s medical judgment. Who is to determine what is, or is not, medically necessary?

With the increasing use of data mining to detect fraud and abuse, providers today can become the target of scrutiny simply based on the number of medical services provided.

Regardless of whether providers are targeted because they are truly engaged in questionable billing or have become the victim of overzealous prosecutors, it’s best to take steps to ensure that your practice doesn’t get scooped up in the wide net that the federal government has cast.

• Providers should create a compliance program that includes, among other things:
• Document, document, document. Complete your paperwork as soon after seeing the patient as possible and make sure that documentation includes as much detail as possible.
• Show not only that care was provided, but also explain why a particular level of care was necessary.
• Ensure that you are providing medically necessary services. Such services must meet standards of good medical practice. That means:

1. Proper and needed for the diagnosis or treatment of the patient’s medical condition
2. Furnished for the diagnosis, direct care, and treatment of the patient’s medical condition
3. Not mainly for the convenience of the patient, provider, or supplier
4. Meeting specific medical necessity criteria

We don’t expect these types of prosecutions to go away any time soon. Our firm can assist you to ensure that you are in compliance or provide legal counsel if you become the target of an investigation. Contact us for a consultation.