Reporting hospital outpatient fraud
This article shows you how to get a reward for reporting Medicare/Medicaid fraud by reporting hospital outpatient fraud. Below are examples of hospital outpatient fraud followed by tips for reporting hospital outpatient fraud and how to obtain a reward.
Examples of hospital outpatient fraud for upcoding CPT or APC codes
Typically, Medicare pays for hospital outpatient services on a rate-per-service basis, which is based upon the level of service needed by the Medicare patient. For instance, if a person complains of a cold, the hospital receives a set fee for the treatment regardless of how much it actually costs to treat the patient. The hospital is required to select the appropriate ambulatory payment classification (APC) group to which the service is assigned, and the Healthcare Common Procedure Coding System (HCPCS) codes (which include certain Current Procedural Terminology (CPT) codes. It is hospital outpatient fraud for a hospital to bill to a higher CPT code or APC group or lie about the diagnosis.
Examples of hospital outpatient fraud for inflating fees
Not every hospital outpatient medical service is paid on the OPPS or CPT/APC code basis. In fact, several services are paid on a per cost basis or fee schedule, including ambulance, physical and occupational therapy, and speech-language pathology services. It is hospital outpatient fraud to inflate fees for these type of services.
Hospital outpatient fraud for billing for services not rendered or medically necessary
Certainly it is also fraud for a hospital to bill for services not rendered or providing medically unnecessary services.
Hospital outpatient fraud for violating the 72 hour rule
Medicare requires hospitals to combine or bundle into one bill any outpatient diagnostic or other medical services performed within 72 hours prior to being admitted to the hospital must be bundled into one bill. This is known as te “72 hour rule.” In other words, the 72 hour rule mandates that any outpatient hospital services performed within 72 hours of inpatient services be treated or considered as one claim and must be billed together rather than separately. Examples of outpatient procedures that are covered by the 72 hour rule include diagnostic services, such as radiology, lab tests, CT scans, EKGs, cardiology, anesthesia, osteopathic services. Hospitals that routinely or knowingly fail to comply with the 72 hour rule are liable to repay the overpayment. And it may violate the False Claims Act.
Tips for reporting hospital outpatient fraud
It is not enough to call a Medicare or Medicaid fraud hotline to get a whistleblower reward for reporting hospital outpatient fraud. Instead, you must formally apply for a reward for reporting hospital outpatient fraud by having your attorney (on a contingency basis) file a qui tam suit under the False Claims Act.
In addition, your attorney must strictly follow all of the exacting procedures of the whistleblower reward statute to get a reward for reporting hospitals cheating or defrauding Medicare or government healthcare programs through hospital outpatient fraud.
Moreover, you also need to have specific and detailed evidence of hospital outpatient fraud. The government needs your help in uncovering fraudulent billings in hospital outpatient services. However, because most whistleblower reward applications lack specific proof of fraud (or contain another defect), the government turns away most reward applications. That’s why selecting an experienced attorney that has handled many Medicare fraud cases is very important.
How much reward for reporting a hospital outpatient fraud?
The amount of a whistleblower reward for reporting hospital outpatient fraud is based upon the amount the government recovers back, and the reward is between 15% and 25% of what the government collects from the hospital cheating Medicare. For instance, if hospital outpatient charges cheat Medicare by $10 million, the amount of the whistleblower reward could be between $1.5 million and $2.5 million.
How to report a hospital outpatient fraud
This website (and books written by Mr. Hesch) walk you step-by-step through the entire process of reporting hospital outpatient fraud by hospitals and shows you how to obtain a whistleblower reward.
Mr. Hesch has considerable experience with investigating Medicare fraud against the federal government while working for 15 years at the Civil Fraud Section of the U.S. Department of Justice in Washington, D.C., which is the office with nationwide authority over the whistleblower reward program. He now represents whistleblowers and confidentially reviews information to determine whether and how to report hospital outpatient fraud.
The link below “Do I have a case” shows you how to ask Mr. Hesch to review your allegations that a hospital outpatient company fraudulently billed Medicare or another government healthcare program.