Billing

Describes motivation process for creativity with emphasis on intrinsic motivation by Corey K Katir

From How to Get Out of Debt

The Military Star Card is a credit card that is marketed and promoted to military personnel. In the past it was known as the AAFES card as well. This card is limited to use at military Exchange stores or through the Exchange website. Only people who are active duty military, military retirees, reservists, National Guard [...]

Read the full article at GetOutOfDebt.org, click here: Military Star Card / Military Star Rewards MasterCard / AAFES Card- What You Need to Know First

In this edition of The Un-Billable Hour, host Attorney Rodney Dowell, Director of the Massachusetts Law Office Management Assistance Program, talks about value billing and using transparent pricing to become more competitive. Rodney welcomes Attorney Jay Shepherd from the Shepherd Law Group, P.C , to discuss his thoughts on value billing and his passion for providing aopen/transparent pricinga to deliver value to his clients.

When it comes to record-breaking Medicare fraud busts, the hits keep coming.  The feds announced today another nationwide takedown of physicians and other healthcare providers for Medicare fraud totaling in excess of $450 million.  All told, 107 people have been charged in this week’s bust for, among other things, submitting false claims to the Medicare program.  Read more about it here.  

While these headline-grabbing takedowns usually involve some pretty egregious billing practices, law-abiding physicians and other providers should still take note as it is inevitable that the government’s increased efforts to identify fraud will also identify billing errors and inadvertent overpayments.  If you are not regularly having your charts and billings audited by an independent auditor under attorney-client privilege, it is highly advisable to begin doing that regularly as the basis of a practice compliance program.  For more information on developing a cost-effective  practice compliance program, click here.

In June of 2011, I reported on this blog about a software program being launched by the federal Department of Health and Human Services to use a technology called predictive modeling to identify fraudulent and abusive billing practices on a prepayment basis.  The program, known as the Fraud Prevention System, was funded through the The Patient Protection and Affordable Care Act of 2010 and carried an initial price tag of $77 million.  According to the Associated Press, initial results are back on use of the Fraud Prevention System and they are pretty disappointing.  Specifically, according to a recent article published by the AP, the program identified only a single case of fraud which resulted in him him him him him him him Medicare savings totaling $7,591. 

Medicare officials say it’s too early to judge the system’s effectiveness and, on its blog, the White House stated on Friday that “predictive modeling has identified 2,500 leads for further investigation, 600 preliminary law enforcement cases under review and resulted in 400 direct interviews with providers who would not have otherwise been contacted.”   Clearly there are some bugs in the system to be worked out but it appears that HHS is not yet ready to pull the plug on the program.

By David Restaino, Esquire

Federal prosecutors continue to focus their efforts on preventing health care fraud, as evidenced by a recent case arising in Texas. Earlier this year, a Houston doctor (Dr. Christina Clardy) was convicted of three counts of mail fraud, 14 counts of health care fraud and one count of conspiracy to commit health care fraud – all relating to over $45 million in false billings to Medicare and Texas’ Medicaid programs. In particular, the scheme involved a nursing service having billed over $25 million in physical therapy services under Dr. Clardy’s physician provider numbers.

The documents produced at trial included a letter from the doctor showing her knowledge of the fraudulent activities, specifically, requiring her employer’s owner to immediately cease all billing under her number or she would notify the authorities – which she never did even though the billings continued. The evidence against Dr. Clardy was compounded by her receipt of large cash payments from the owner soon after her letter was sent.

The Court recently announced its sentence against Dr. Clardy. The sentence serves as a clear warning to physicians who are tempted by the illegal profits to be made from defrauding Medicare and Medicaid: Dr. Clardy will be spending 135 months in federal prison and must personally pay over $15 million in restitution. This sentence is in addition to the separate sentences handed out against two other convicted defendants involved in the scheme; a fourth person will be sentenced this month.
 

By Christopher E. Hale

Contractors pursuing claims against the government under the Contract Disputes Act (“CDA”) can often fall victim to the jurisdictional pitfalls of the Act from the very start of the claims process, i.e., with the claim itself. After a contracting officer denies a claim under the CDA, a contractor can appeal the decision to either a Board of Contracts Appeals or the U.S. Court of Federal Claims. However, there is no shortage of cases in which such appeals are dismissed for lack of jurisdiction because the original requests for payment did not constitute “claims” under the CDA.

One recent illustration of this problem involved the distinction between routine and non-routine requests for payment, as addressed by a recent split-panel decision of the United States Court of Appeals for the Federal Circuit, Parsons Global Services, Inc. v. Secretary of the Army, No. 2011-1201 (Fed. Cir. Apr. 20, 2012).

The case centered on the termination for convenience of several task orders under an indefinite-delivery-indefinite quantity contract awarded by the Army to Parsons for design-build work in Iraq. Parsons had entered into a subcontract with Odell International, Inc. (“Odell”) to construct health care facilities and deliver medical equipment in Iraq pursuant to the prime contract.

Shortly before the task orders were terminated for convenience by the Government, the Defense Contract Audit Agency (“DCAA”) determined that Odell had been mistakenly billing Parsons using a lower overhead rate than was specified in the subcontract. Odell then invoiced Parsons for the difference, but Parsons refused to pay the invoice and submitted a termination settlement proposal to the Termination Contracting Officer (“TCO”) without including the disputed Odell costs. Two years later, as part of settlement of the prime contract, DCAA audited Parsons’ billed costs, including Odell’s costs, and determined that Odell’s costs at the higher overhead rate were supported and appropriate. Odell submitted a new invoice for the difference, and Parsons submitted three payment requests for the additional Odell costs to be paid directly by government. The TCO declined to act on the requests to settle directly with Odell. Parsons then submitted a sponsored “Certified Claim for Payment” under the CDA on behalf of Odell to the Procurement Contracting Officer (“PCO”), and appealed the PCO’s denial of the claim to the Armed Services Board of Contract Appeals (“ASBCA”).

The Government moved to dismiss for lack of jurisdiction, arguing that Parsons’ routine request for payment to the PCO did not amount to a claim under the CDA. Parsons countered that, because its requests for payment occurred two years after the termination of the task orders and thus could not be subject to routine invoicing and termination procedures, the request was non-routine and sufficient by itself to constitute a claim. The ASBCA sided with the Government and dismissed the claim.

On appeal, the Federal Circuit affirmed the ASBCA’s decision, holding that Parsons’ request for payment was not a claim as defined in FAR 2.101. Under the FAR, demands for payment can be classified as either “routine” or “non-routine.” If the request is “non-routine,” then it constitutes a claim under the CDA so long as “it be (1) a written demand, (2) seeking, as a matter of right, (3) the payment of money in a sum certain.” However, if the request is “routine,” a pre-existing dispute is necessary for it to constitute a claim under the CDA.

As the Federal Circuit detailed, non-routine requests for payment typically spring from additional or unforeseen costs not covered by the contract:

Such requests include requests for equitable adjustments for costs incurred from “government modification of the contract, differing site conditions, defective or late-delivered government property or issuance of a stop work order” and other government-ordered changes; for damages resulting from the government’s termination for convenience and termination settlement proposals that have reached an impasse; for compensation for additional work not contemplated by the contract but demanded by the government; for the return of contractor property in the government’s possession; and for damages stemming from the government’s breach of contract or cardinal change to the contract.

In contrast, according to the Federal Circuit, the request for payment of Odell’s costs made to the PCO was routine because the costs were explicitly covered by the contract and, but for the billing error, would have been subject to routine invoicing during contract performance. Furthermore, the routine request was not subject to a pre-existing dispute because the PCO, the appropriate official to evaluate the request, never received a proper request for payment prior to the improper “Certified Claim for Payment.”

In a somewhat scathing dissent, Judge Newman posited that major billing errors, such as Odell’s, are neither foreseen nor intended and cannot be characterized as routine. However, stepping away from the esoteric classification of routine and non-routine requests for payment, Judge Newman threw the facts of the case – in which “a simple correction of a billing error has morphed into a nearly four-year litigation, with no end in sight” – into sharp relief:

The agency’s refusal to pay Parson’s claim, having acknowledged the obligation and having audited it through its own Audit Agency, is contrary to the guiding principle that “The Federal Acquisition System will [c]onduct business with integrity, fairness, and openness.” . . . . This lengthy litigation of a conceded governmental obligation is an embarrassment.

To avoid being caught in such an “embarrassment,” contractors should take care when submitting claims pursuant to the CDA to ensure that a request for payment that could be classified as routine is subject to a pre-existing dispute. Otherwise, the contractor might find years later that its claims process was flawed from the start and must begin anew – assuming the statute of limitations has not already run its course.

By Joseph Barton

On May 2, 2012, Federal agents with the Department of Justice’s (“DOJ”) special task force made the biggest Medicare bust in U.S. history, and a splash in the media, when it cracked down on a number of unrelated Medicare fraud schemes across the country that resulted in an alleged $450 million in false claims being submitted to Medicare over the past six years. A total of 107 people were arrested, including doctors, nurses, social workers, office managers, and patient recruiters. Charges ranged from submitting false billing for home healthcare, mental health services, HIV infusions, and physical therapy, to money laundering and receiving kickbacks.

With the President and Congress under pressure to ensure Medicare’s fiscal sustainability, DOJ has committed itself to vigorously investigating and prosecuting Medicare fraud. The FBI currently has 500 agents and analysts investigating 2,600 cases of alleged healthcare fraud and has charged 1,300 people since 2007 for submitting false claims to Medicare. In addition, Lanny Breuer, the head of the DOJ’s criminal division, has commented that the recent Medicare busts should serve as a reminder to health care providers that they “risk prosecution and prison time every time they submit a false claim.”

With the Federal Government taking aim at Medicare fraud, here are few things for which healthcare providers should be on the lookout:

• Kickbacks: The federal Anti-Kickback Statute, 42 U.S.C. §1328-7b(b), prohibits any offer, payment, solicitation, or receipt of money, property, or remuneration to induce or reward the referral of patients or healthcare services payable by Medicare. These improper payments can come in many different forms, including: referral fees, finder’s fees, productivity bonuses, discounted leases, discounted equipment rentals, research grants, speaker’s fees, excessive compensation, and free or discounted travel or entertainment. Kickbacks can also constitute a violation of the federal False Claims Act (“FCA”), 31 U.S.C. §§ 3729-3733.
• Up-Coding: Billing Medicare involves a complex series of codes that assign a dollar value to the procedures and services performed based on their complexity. Up-coding occurs when a claim is submitted for a more complex procedure than was actually performed. Up-coding is a favorite target of health care- related FCA claims.
• Unbundling and Bundling: Medicare has special reimbursement rates for groups of procedures that are typically performed together, such as laboratory tests. “Unbundling” occurs when bundled procedures are billed separately in order to exceed the group reimbursement rate. Conversely, “bundling” refers to the artificial combination of tests and procedures in such a manner that they are not separately available, which results in the performance of and billing for unnecessary tests. Unbundling and bundling can constitute violations of the FCA.
• False Certifications: When physicians, hospitals, and other health care providers submit bills to Medicare, they are required to include a number of certifications, including that the services were medically necessary, were actually performed, and were performed in accordance with all applicable rules and regulations. False certifications are easy prey for whistleblowers under the FCA.
• Improper Financial Interests: The federal Stark law, 42 U.S.C. §§ 1395nn and 1396b, generally prohibits physicians and members of their immediate families from having financial interests in entities that perform certain designated health services to which they refer patients or from which they order goods and services paid for by Medicare.

By keeping an eye out for these types of practices, which are commonly targeted for Medicare fraud allegations, healthcare providers can avoid substantial liabilities.

For the fourth time in 14 years, the Federal Trade Commission has taken action against the nation’s largest charge-it-to-your-phone-bill company, Billing Services Group (BSG), for alleged “cramming,” or placement of unauthorized charges on consumers’ phone bills. You’ve probably never heard…

The Federal Communications Commission today launched a new ‘bill shock’ website that tracks how the major U.S. wireless carriers alert you when you’re at risk of going over your usage limits for voice, data, and text. Bill shock is the…

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