When Medicare Demands a Refund


The Department of Health and Human Services, Office of Inspector General has been conducting massive fraud sweeps of its contractors and programs. With an eye to reducing waste and mismanagement, the HHS and OIG are now going after multi-site healthcare organizations like never before with a complete revamp of rules unseen in 15 years. And they’re not stopping on obvious quality of care abuses. These departments are auditing for past Medicare invoicing – and demanding refunds for services they have identified as over-billing. According to experts, small and mid-sized providers should be particularly alert to Medicare Secondary Payer Compliance since their billing systems are frequently not as advanced as hospital systems or large medical groups.

On November 30, 2017, the OIG posted its Semiannual Report to Congress, which is a summary of the OIG’s activities from April 1, 2017, to September 30, 2017. The Inspector General, Daniel Levinson, reported during FY 2017 the total figure of expected recoveries rose to $4.13 billion, and included criminal action against 881 individuals or entities that engaged in crimes against HHS programs, the exclusion of 3,244 individuals and entities from Federal healthcare programs, and civil actions against 826 individuals or entities.

As part of the OIG’s overall concerns about questionable prescribing of Medicare Part D, OIG and law enforcement conducted the largest National Health Care Fraud Takedown in history and charged 120 health care professional defendants for their roles in prescribing and distributing opioids. The government also charged than 400 defendants in 41 Federal districts with participating in fraud schemes involving about $1.3 billion in false billings to Medicare and Medicaid.

Defending Yourself Against Medicare Fraud Claims

But can an “overbilling” refund be challenged? Defending oneself against quality of care investigations is only part of the puzzle. Today, billing issues are quality of care issues. And comprehensive quality of care issues is how ALN has served clients for many years.
ALN Consulting takes a proactive approach to new governmental guidelines and looming audit possibilities. With HHS’s new guidelines in full force, we can review your current records and educate your staff about potential red flags in light of new HHS compliance. LNCs can determine what issues are avoidable and which are not. We offer the best possible preparation for an audit that could happen at any time.

But if the OIG contacts your office before your audit preparation is in place, ALN is ready to help you step by step. First, our legal nurse consultants will investigate the degree of accuracy of the governmental assessment. From there, we will work with you to develop a strategy and assemble appropriate clinical documentation to defend and manage against that claim. Our experienced consultants create case studies which support the beneficial services your staff has rendered and justify the so-called “overbilling” and “worthless service” claims that were flagged by the HHS.

Like many other industries, the healthcare and insurance communities must prepare themselves for audits of financial compliance as well as industry-specific issues. Mitigating a hefty government penalty is only part of the investment you make with your legal consultant. ALN can be your best defense against government bureaucracy…and groom you for the new normal in healthcare compliance.

ALN Consulting is a national provider of medical-legal consulting services, founded in 2002. Our expertise includes, yet is not limited to, medical malpractice, long-term care, product liability, class action/mass litigation, and toxic tort. Contact Us to put our legal nurse consulting experts on your case.

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