The  recent criminal sentencing and civil settlement of Illinois physician Dr. Mahmoud Yassin highlights the growing- but too often appreciated exposure of physicians and other health care providers and their billing or other management who submit conflicting claims data to private and government claims or otherwise permit in false  falsely bill or participate in the cover-up of fraudulent or other improper billings to payers.  The Yassin sentencing is notable both because Yassin incurred criminal liability for obstruction based on his presentation of altered patient records to a private payer and and civil liability for  making false claims to Medicare and others.

The Yassin prosecution demonstrates the importance of providers getting their records and billings straight when billing both private payers and government payers.  While most  health care providers recognize  the significant exposure they incur from overbilling Medicare or other federal programs as a result of the highly publicized, heavy-handed audit and enforcement activities of the Centers for Medicare & Medicaid Services (CMS), the Department of Health & Human Services Office of Inspector General (OIG) and Department of Justice (DOJ), many  don’t recognize their exposure from private payer billings or the potential interaction between private and government claims investigations  Amendments enacted as part of the anti-fraud provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) added private health plans to the list of plans protected by federal prohibitions against fraudulent billing by providers.  Furthermore, federal fraud investigators and private payers increasingly are working together on the investigation and redress of false billing and other aggressive practices.  These and other risks mean that providers cannot afford to be unprepared when asked to respond to investigations like one that lead to the Yassin conviction, recoupment or other audit and enforcement actions  See,  Secondary Payers Hit Physician Group With Recoupment After Medicare Audit Findings.   Rather, physicians and other health care clinics must be ready to prove and defend their billings to public and private payers.  In both cases, these preparations should ensure that records accurately and completely document the care provided, that the coding and billing applied is reflective of actual care and consistent with existing reimbursement, and otherwise defensible.  As demonstrated by Yassin, inconsistencies between records presented to different payers should be avoided.

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to establish and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her presentations and programs include a wide range of compliance, risk management and other workshops, programs and publications.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.  You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see  here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

• Hollywood Pavillion & Other Fraud Convictions Show Individuals Risk Prison Time For Health Care Fraud Involvement
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• Whistleblower Collects $2.7 M of $14.5M Sound Inpatient Physicians Overbilling Settlement
• OIG Urges CMS To Step Up Efforts To Recover “Overpayments”
• Ambulatory Care Orgs Face New Joint Commission Standards Beginning January 1, 2014
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• Hospital Pay $275K To Settle HIPAA Charges After Sharing PHI With Press, Workforce In Response To Fraud Reports
• OCR Makes Technical Corrections To HIPAA Omnibus Final Rule;  September 2013 Enforcement Deadline Looming
• National Provider Calls: Medicare Shared Savings Program Application Process — Register Now
• Feds Arrest 36 More California & Florida Providers On Defrauding Medicare Of More than $66 Million
• CMS Proposes To Further Tighten Medicare Provider Enrollment Rules
• HHS Proposes Increasing Health Care Fraud Reporting Rewards To Up To $9.9 Million
• CMS Proposes Changes To Accute Care Hospital & Skilled Nursing Facility Prospective Payment Rules
• OCR Shares New Tools to Educate Consumers and Providers about HIPAA Privacy and Security
• Bad Economy, Not Health Care Reform Accounts For Slowing Health Care Cost Trend
• Amgen Settlement Highlights Anti-Kickback Exposures From Whistleblowers, Need For Effective Compliance & Risk Management

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here. For important information about this communication click here. 

THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TO U.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS.  ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2013 Cynthia Marcotte Stamer, P.C.  Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

This entry was posted on Tuesday, July 23rd, 2013 at 11:56 am and is filed under Accreditation, Ambulatory care, ASC, Doctor, Employer, Health Care, Health Care Finance, Health Care Provider, Health Care Quality, Hospital, Joint Commission, Medical Licensure, OIG, Physician. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.