When Inside Knowledge Is a Handicap to a Whistleblower

Here’s a riddle: The whistleblower is a former employee of the defendant, with inside knowledge of the operations at the heart of his qui tam suit.  How can that inside knowledge be a handicap in pressing his claim?  A June 21 decision by a Massachusetts federal court provides an answer and an …

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Site-Neutral Billing Exemptions

The Balanced Budget Bill Act of 2015 has a site-neutral billing provision relating to off-campus hospital outpatient departments (HOPDs).   Those are facilities away from the hospital campus but certified as part of the hospital and therefore qualified to receive a facility fee, like the hospital itself.  …

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Biblical Name No Shield Against Fraud Charge

On May 2 a New Orleans federal jury found that Psalms 23 DME, LLC—its Biblical name notwithstanding--was part of a fraud scheme that illegally billed Medicare $3.2 million. In 2013 the government indicted Psalms 23 owner Tracy Brown and a colleague for a fraud scheme that involved billing Medicare for …

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There Is Such a Thing as Being Too Careful

According to The New York Times, Medicare may be punishing hospitals—and academic medical centers (AMCs) in particular—for being too careful.  That’s how Northwestern Memorial Hospital’s chief medical officer sees the practical effect of Medicare’s policy of reducing payments to the hospitals with the …

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New Guidance on Exclusion

For the first time in nearly 20 years the Office of Inspector General (OIG) of the Department of Health & Human Services has issued new guidance on the exercise of its authority to exclude health care providers from participating in federal health care programs, including Medicare, Medicaid, and Tri-Care.  …

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Texas-Size Sentences for Texas-Size Medicare Fraud

They do things big in Texas.  The latest example is the punishments being handed out for a Medicare fraud scheme at Riverside General Hospital in Houston. Let’s start with the fraud scheme.  It was Texas-size, too, resulting in a whopping $158 million in false Medicare claims for partial hospitalization …

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