Breaking Compliance News Blog

Compliance lessons from recent fraud cases

Posted by Scott Gima on 7/20/22 9:15 AM


Outlier billing patterns will get you noticed!

A New York ENT physician was convicted of filing false claims with Medicare and Medicaid. The physician submitted claims totaling about $585,000 to Medicare and Medicaid and was paid roughly $191,000.

The fraudulent act was upcoding of ear exams or ear wax removal to an incision procedure of the external ear. An analysis of Medicare and Medicaid data identified this physician’s billing was an outlier and was found to be the highest biller for this procedure in the State of New York. 

Compliance lesson: Enforcement agencies are actively using data analytics to identify, investigate and prosecute providers with unusual billing activity – and so should you. Audit your claims regularly to identify potential false claims, so they can be corrected and/or reported.


Mole billing fraud scheme totals $4.1 million in false claims over 7 years

The second case involves a Chicago physician who conducted cancer screenings on moles that were removed from his patients. The US Attorney’s office in the Northern District of Illinois recently filed charges in the US District Court in Chicago. The press release includes the allegation that the physician removed more moles from patients than was medically necessary, totaling $4.1 million in fraudulent payments between 2015 and 2021.

But how does a simple case of removing one mole but billing for removing multiple moles leads to $4.1 million? Well, it turns out that the scheme was, shall we say, creative. Here is what was included in the charge document:

  • More moles were removed that were medically necessary
  • If multiple moles were removed from one area of the body, false documentation would be created to indicate that the moles were removed from different areas of the body
  • When multiple moles were removed from a patient, the specimens would not be submitted immediately to pathology
  • The practice would instead submit one specimen at a time to pathology on different days
  • False documentation was created to show the removal of a single mole on different visits
  • Some of the fraudulent visits were submitted on days when the physician was out of town
  • Fraudulent documentation was submitted in response to Medicare audits

That is how you collect $4.1 million in false claims over a seven-year period.

Compliance Lesson: Examples like this fall into the category of “truth is stranger than fiction.” It is impossible to draft policies and train staff on for every possible compliance risk scenario. The goal of an effective compliance program is to train employees and staff to trust their instincts – if something does not seem right, notify the compliance officer directly or anonymously.


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Topics: Penalties and Enforcement, Billing and Claims Submission

OIG finds 61% therapy services error rate

Posted by Margaret Scavotto, JD, CHC on 5/23/18 7:02 AM


In March 2018, the OIG issued Report A-05-14-00041, Many Medicare Claim for Outpatient Physical Therapy Services Did Not Comply with Medicare Requirements

The OIG reviewed 300 random Medicare outpatient PT claims for services provided between July and December of 2013.

Based on its review, the OIG found:

  • 61% of outpatient Medicare PT services did not comply with Medicare requirements.
  • Medicare paid an estimated $367 million for these services.

The OIG identified three types of claims errors: medical necessity, coding, and documentation. Here is a breakdown of the errors by type:

Medical Necessity Errors (91 claims out of 300)

  • 98%: Services not reasonable
  • 33%: Services not effective
  • 31%: Services did not require the skills of a therapist
  • 29%: No expectation of significant improvement

Coding Errors (145 claims)

  • 59%: Timed units claimed did not match units in treatment notes
  • 54%: Missing modifiers
  • 41%: Incorrect codes

Documentation Errors (112 claims)

  • 71%: Plan-of-care deficiencies
  • 66%: Treatment note deficiencies
  • 8%:  Recertification deficiencies

Providers of outpatient physical therapy can expect increased claims monitoring by CMS, as well as more education from CMS.

Same song different tune?

 While this review focused on outpatient physical therapy provided in an office setting, the OIG has similar concerns about therapy provided in nursing homes.  A 2012 OIG report found errors involving coding, medical necessity, and documentation in SNFs.

In November 2012, the OIG released a report: Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More than a Billion Dollars in 2009.    

The OIG found that 25% of all SNF Medicare claims were erroneous. The errors included:

  • 20.3%: Claims with an inaccurate RUG (upcoded). In 57% of these claims, SNFs provided more therapy on the MDS than was documented in the medical record; and 25% of these claims involved therapy listed in the medical record that was not reasonable and necessary
  • 2.5%: Claims with an inaccurate RUG (downcoded)
  • 2.1%: Claims that did not meet Medicare coverage requirements (e.g. no physician order)

The OIG also found that 47% of claims involved inaccurate MDS information. The primary reporting error was the amount of therapy received or needed, followed by special care, ADLs, oral/nutrition status, and skin conditions/treatment.

What you can do

The takeaway here is: whether you are providing outpatient therapy, skilled nursing therapy – or another Medicare service involving therapy – medical necessity, documentation and coding errors remain common errors of OIG concern. Incorporating these items into your regular compliance audits will help you find and correct errors internally and improve claims accuracy.

compliance risk assessment annual review

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Topics: Auditing and Monitoring, Billing and Claims Submission, OIG compliance resources

The government is monitoring your claims data. Are you?

Posted by Margaret Scavotto, JD, CHC on 1/9/18 7:05 AM

Chemed Corporation, Vitas Hospice Services LLC, and Vitas Healthcare Corporation entered a $75 million settlement with the government to resolve false claims allegations. Vitas, the biggest for-profit provider of hospice services in the nation, allegedly “knowingly submitted or caused to be submitted false claims to Medicare for services to hospice patients who were not terminally ill” between 2002 and 2013. The DOJ also accused Vitas of awarding bonuses to employees based on the number of patients on hospice, regardless of need.

In addition, Vitas was accused of billing Medicare for continuous home care services that were not necessary, not provided, or did not meet Medicare requirements. Like with hospice services, Vitas allegedly set corporate goals for billing continuous home care services, regardless of patient need.

According to the Complaint, “Vitas regularly ignored concerns expressed by its own physicians and nurses regarding whether its hospice patients were receiving appropriate care.” Complaint, page 3. The Complaint also says the company’s own auditors knew of the problem – but changes were not made.


Let’s look at the data

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Topics: Penalties and Enforcement, PEPPER, Auditing and Monitoring, Billing and Claims Submission

PEPPER 2015 Is Here! Are You An Outlier?

Posted by Margaret Scavotto, JD, CHC on 4/16/15 1:44 PM

PEPPER (Program for Evaluating Payment Patterns Electronic Report) reports for Q4FY14 have been released--a few days ahead of schedule! You can access your PEPPER online.

This latest PEPPER uses statistics through September 2014, and will be available for download for approximately two years.

To download your PEPPER, the CEO, President or Administrator of the SNF needs to:

  1. Visit the PEPPER Resources Portal
  2. Enter your information. You will need a Patient Control Number (form locator 03a on the UB04 claim form) *or* a Medical Record Number (form locator 03b on the UB04 claim form) for a claim of a traditional fee-for-service (FFS) Medicare patient/beneficiary who was receiving services at this provider between September 1 - 30, 2014 (“From” or “Through” date on the claim is between September 1 - 30, 2014).
  3. Download your PEPPER.

If you need help, review the Secure PEPPER Access Guide.

Not a SNF?

PEPPER might still be coming soon:

 And, for the first time in 2015, PEPPER will be released for home health (expected in July).

Now what?

Learn more about how to use PEPPER as part of your compliance program's auditing strategy.

Are you an outlier? Download  MPA's Guide to  PEPPER Reports  to find out

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Topics: PEPPER, Auditing and Monitoring, Billing and Claims Submission

Nursing Home pays $500,000 for therapy provided by contractor

Posted by Margaret Scavotto, JD, CHC on 7/9/14 1:08 PM

The United States Department of Justice recently entered a $500,000 settlement with an Iowa skilled nursing facility, to resolve allegations that the SNF billed the government for improper therapy provided by a third party therapy services contractor.

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Topics: Penalties and Enforcement, PEPPER, Billing and Claims Submission, medical necessity, Therapy

PEPPER Outlier Reports: Are you part of the 49%?

Posted by Margaret Scavotto, JD, CHC on 7/7/14 3:25 PM

The latest Program for Evaluating Payment Patterns Electronic Reports (PEPPER) reports for SNFs, from 4th Quarter 2013, have been available since May 5. As of June 30, only 49% of SNFs have accessed their PEPPER reports. Are you one of the 49%?

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Topics: PEPPER, Auditing and Monitoring, Billing and Claims Submission

PEPPER Is Here! Are You An Outlier?

Posted by Margaret Scavotto, JD, CHC on 5/13/14 3:41 PM

SNFs can now access their PEPPER (Program for Evaluating Payment Patterns Electronic Report) for 4th Quarter 2013 online.

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Topics: PEPPER, Auditing and Monitoring, Billing and Claims Submission

PEPPER Reports Are Coming: Are You Ready?

Posted by Margaret Scavotto, JD, CHC on 4/17/14 3:07 PM

CMS Program for Evaluating Payment Patterns Electronic Reports (PEPPER) reports will be released soon. PEPPER is a Medicare Part A claims data report that compares your SNF to state, national and MAC or FI jurisdiction data. PEPPER includes this comparative data for six Target Areas:

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Topics: PEPPER, Auditing and Monitoring, Billing and Claims Submission

OIG Releases Work Plan for Fiscal Year 2014

Posted by Margaret Scavotto, JD, CHC on 2/7/14 11:17 AM

On January 31, the OIG released its Work Plan for Fiscal year 2014 (which began on October 1, 2013). The Work Plan sets out the items the OIG will be reviewing during this fiscal year—and is a great tool to help Compliance Officers direct their compliance audits.

The work plan is about 100 pages, but don’t let that overwhelm you. It covers the entire health care industry, so the key is to find the pieces that apply to your organization. For example, the following items pertain to Nursing Homes:

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Topics: Breaking Compliance News Blog, Quality Assurance, Billing and Claims Submission

Who is responsible for billing compliance?

Posted by Gary Winschel on 12/18/13 12:12 PM

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Topics: Billing and Claims Submission, medical necessity

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