which docs and practices WERE in fact busted for quite a lot of money.
There's actually a lot of activity in this area, and the government has a great interest in pursuing this. Of course I'm sure there's plenty they don't catch.
http://www.usatoday.com/money/industries/health/2005-03-02-tenet-usat_x.htm Tenet accused of $1 billion Medicare fraud
By Julie Appleby, USA TODAY
Florida's attorney general filed a civil racketeering lawsuit against Tenet Healthcare on Wednesday, alleging that the hospital chain drove up its prices to collect about $1 billion from a special Medicare fund.
The charges, filed in U.S. District Court in Miami, are similar to concerns raised by federal regulators investigating the company's billing practices. Those inquiries are ongoing.
The Medicare "outlier payment" fund compensates hospitals for caring for sicker-than-average patients by granting extra payments when the cost of a patient's care exceeds a threshold.
By raising its prices nationally to an average 477% over actual costs, the lawsuit alleges that Tenet received a larger share of those Medicare funds and drove up the minimum threshold other hospitals had to meet to qualify for payments. The case alleges that Florida hospitals lost millions as a result.
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http://www.usdoj.gov/dag/pubdoc/health98.htm Significant Cases
FY 1998 saw the conclusion of two major investigations involving allegations of fraud on the part of the contractors who process claims on behalf of the Medicare program. Health Care Services Corporation, the Medicare carrier for Illinois and Michigan, agreed to pay the government $140 million in settlement of a qui tam suit alleging that it shredded claims, altered documents and otherwise manipulated data relied on by the HCFA to evaluate its contract performance. In addition to the civil settlement, the corporation agreed to plead guilty to obstructing a federal audit, conspiracy to obstruct a federal audit, and making false statements to HCFA which will result in a $4 million criminal fine. In order to guard against future misconduct, and to ensure that any potential lapses are detected early, the government and the corporation also entered into a strict corporate integrity agreement.
Pennsylvania Blue Shield, the Medicare carrier for several mid-Atlantic states, resolved a 2-year investigation by agreeing to pay $38.5 million in settlement of allegations that it improperly processed Medicare secondary payor claims, neglected to recover overpayments, bypassed certain computer payment safeguards, and failed to implement required screens for certain lab tests, all of which resulted in false claims to the Medicare program. Again, the contractor agreed to undertake corporate integrity obligations, including training and external reviews of its performance.
In the area of psychiatry, an Atlanta businessman was sentenced to 3 years and 10 months and ordered to pay $7 million in restitution for defrauding HHS, the State of Georgia Department of Medical Assistance, and certain Medicaid recipients, through a complex scheme involving billing Medicaid for individual and group psychotherapy allegedly provided to children. The scheme involved employees going door-to-door in impoverished areas to recruit children for after school programs, typically failing to inform parents that Medicaid would be billed for psychotherapy allegedly provided to their children. These services were not necessary and not actually provided to the children.
Smaller but significant settlements were reached in relation to defective pricing and pharmaceutical suppliers. Invacare Corporation agreed to pay $2.6 million to the U.S. Department of Veterans Affairs to settle allegations of fraud in the sale of wheelchairs. The corporation failed to provide accurate and complete cost data during contract negotiations. An Illinois supplier of drugs and pharmaceutical products pleaded guilty to making false statements to the Illinois Department of Public Aid concerning fraudulent bills submitted to them, the Corporation also agreed to pay $5.3 million to the U.S. Government and the State of Illinois. The defendant established a procedure in which medications that were returned to the pharmacy were placed back into inventory without crediting the Illinois Department of Public Aid, which had paid for the drugs.