Medicare is a federally-funded program that "provides subsidized medical insurance for the elderly and certain disabled people." According to 2013 estimates by the National Committee to Preserve Social Security, some 52.3 million Americans currently rely upon Medicare for their primary health and medical needs.
Along with strict eligibility requirements for Medicare participants, healthcare providers and facilities must also abide by to very specific requirements and policies with regard to the type and timing of care being provided. Unfortunately, according to the U.S. Department of Health and Human Services, Medicare fraud is fairly common as both individual providers and large healthcare companies knowingly submit false billing statements, take advantage of referral programs and incorrectly code claims.
In what's being heralded as "one of the biggest whistleblower cases of the country," a reported 457 hospitals across the U.S. have settled cases related to Medicare fraud for a total sum of approximately $258 million. Under the False Claims Act, a person who "knowingly submits, or causes the submission of, a false or fraudulent claim to the federal government," may be deemed civilly liable. Additionally, criminal charges may also be brought in such matters.
Four large hospital chains recently reached a settlement with the government related to Medicare false-claims violations. According to court records, an investigation into acts of Medicare fraud at U.S. hospitals began seven years ago after two separate whistleblowers filed lawsuits. In the years that followed, it was revealed that hundreds of hospitals were routinely violating Medicare requirements with regard to the timing of performing implantable cardioverter defibrillator procedures.
According to federal Medicare regulations, when a patient suffers a heart attack, an ICD cannot be implanted until 40 days or more after the event. Likewise, in cases where a patient undergoes a heart bypass or angioplasty procedure, Medicare requires that a physician wait at least 90 days before moving forward with an ICD procedure.
Despite these guidelines, which help prevent unnecessary and costly procedures, court documents reveal that time and time again physicians at hundreds of hospitals performed ICD procedures in advance of the waiting period elapsing.
Source: New York City Today, "FOUR UPMC HOSPITALS SETTLE THE VIOLATION CASE REGARDING MEDICARE BILLING WITH $5.4 MILLION FINE," Diane Hoffman, Nov. 1, 2015
Department of Health and Human Services, "Medicare Fraud & Abuse," Nov. 24, 2015