Billing manipulation cited in prominent Medicare fraud litigation

This blog and other legal resources across the country have duly pointed out to readers for some time that the spotlighting and subsequent prosecution of fraud has been a top-shelf — and progressively expanding — focus of regulators in Texas and nationally for the past several years.

As we note on a fraud-defense page of our website at the proven Houston law firm of Hilder & Associates, P.C., “Federal and state governments have made the investigation and criminal prosecution of various frauds a high priority.”

The longstanding False Claims Act outlines the rules, processes and protections relevant to so-called “qui tam” litigation filed by a whistleblower in cases involving fraud committed against the federal government.

Additionally, the federal Dodd-Frank legislation centrally addresses fraud and whistleblower processes/protections in instances of actions taken that violate American securities laws.

And there are of course other core areas that are frequently underscored in reports of fraud probes and prosecution, such as mortgage and bank fraud, insurance fraud and Internet fraud.

And health care fraud. In fact, fraud in the health care industry is indeed the proverbial elephant in the room where fraud-focused inquiry is concerned, given the frankly massive dimensions of relevant government programs (think Medicare and Medicaid) and associated treatment payouts.

The proof of that is in the details, some of which were prominently spelled out in a recent national media report on a just-executed settlement reached by government regulators with two insurance companies.

Those entities are now on the hook for close to $32 million for their alleged manipulation of risk scoring that guides patient treatment outcomes for the Medicare Advantage program. Government officials say that the insurers systematically bumped up scores by exaggerating patient illnesses and falsifying treatment records. The spiked numbers entitled them to greater payments, which regulators say they unlawfully took for years.

Billing-formula tampering in the medical realm has reportedly been a key focus of government investigators and auditors for some time. The above-cited NPR report points to myriad whistleblower lawsuits that have alleged such wrongdoing.