Report Finds Potential Medicare Fraud in Questionable Lab Payments By Tod Aronovitz | 07/14/14 | 0 Comment

Potential Medicare fraud was found among 13 medical procedures in a recent report that showed more than 1,000 clinical laboratories across the U.S. exceeded the thresholds for questionable billing for Medicare lab services. Leading examples include higher-than-average billing, the use of ineligible physician identification numbers, and duplicate tests.

The study, conducted by the Department of Health and Human Services’ Office of Inspector General, reported that Medicare is the largest payer of clinical lab services in the nation, totaling $8.2 billion in 2010 alone.  Of that amount, $1.7 billion was spent on claims to labs associated with questionable billing practices, the study concluded.  From 2005 to 2010, spending for lab services increased by 29 percent; yet, Part B Medicare enrollment increased by only 10 percent, the study found.

More specific analysis revealed that 43 percent of the labs demonstrating five or more measures of questionable billing practices were based in California and Florida, even though just 13 percent of all labs are located in those two states.

According to a news story in the July 9 Wall Street Journal, “Red Flags in Medicare Billing,” clinical lab services including blood counts, cholesterol screenings and urinalyses make it easy to fleece the system because these services are provided by additional parties instead of by physicians directly.  Multiple parties in patient care often open up opportunities for fraudulent activity, Medicare authorities say.

Findings from the study also illustrate how much the Medicare program remains vulnerable to incorrect billings and payments.  According to the Centers for Medicare and Medicaid Services (CMS), improper payments by Medicare added up to $36 billion in 2013, representing an error rate of 10.1 percent.  The agency says that’s a jump from 2012, which saw an 8.5 percent rate of improper Medicare payments representing $29.6 billion.

However, CMS said advanced analytics have helped to identify or prevent more than $210 million in improper Medicare payments overall in the past two years.

Collectively, HHS OIG findings from the study call for even stronger oversight of labs, including the following recommendations for CMS:

  • Reviewing the labs identified as having questionable billing and taking appropriate action
  • Reviewing existing program integrity strategies to determine whether these strategies are effectively identifying program vulnerabilities associated with lab services
  • Ensuring that existing edits prevent claims with invalid and ineligible ordering-physician numbers from being paid.

How to Report Miami Medicare Fraud

Healthcare professionals or medical billing employees who have knowledge of questionable Medicare billing practices can file a confidential legal claim under the False Claims Act. By acting as a “whistleblower” in what is known as a “qui tam” lawsuit, a private party may collect up to 30 percent of the amount recovered, depending on how the case is prosecuted.

ARONOVITZ LAW: Miami Whistleblower / Qui Tam Law Firm

The Miami Qui Tam law firm of ARONOVITZ LAW routinely works with whistleblowers to document Medicare fraud and other forms of fraud against the government. Contact Miami Whistleblower / Qui Tam lawyer Tod Aronovitz to discuss your case.