Breaking Compliance News Blog

DOJ Announces Biggest Health Care Fraud Case Against Individuals

Posted by Margaret Scavotto, JD, CHC on 8/8/16 6:00 AM

Find me on:

The DOJ recently announced the biggest criminal health care fraud case ever to be brought against individuals. The DOJ filed conspiracy, obstruction, money laundering, and health care fraud charges against an owner of 30+ nursing homes, a hospital administrator, and a physician's assistant.

These three individuals are accused of defrauding the Medicare and Medicaid programs of $1 billion.

Yes, you read that right: 3 people. $1 billion.

The DOJ alleges that these three individuals billed Medicare and Medicaid for medically unnecessary skilled nursing services. They are also accused of taking illegal kickbacks from other providers, who in turn rendered medically unnecessary services to these patients.

This example hopefully seems egregious, but should have even the most ethically-minded compliance officers asking: 

Do we know the claims we submit to Medicare and Medicaid are medically necessary?

How do we know?

Can we prove it?

Your compliance auditing program can help you verify your claims are reasonable and appropriate:

  • Conduct medical necessity audits of your claims and medical records. If this task seems burdensome, start with a small sample size and a quarterly audit, and work up to monthly audits with a larger sample size.
  • Use the results of the medical necessity audits to provide documentation education to your staff.
  • Monitor your PEPPER data at least quarterly, conducting chart reviews where warranted.


compliance risk assessment annual review

Topics: Penalties and Enforcement

    Privacy Policy           Terms of Use