October 31, 2014

Medicaid, Medicare

Lawmakers Aggressively Tackle Healthcare Fraud

Amy Keller | 1/1/2010

Joining the battle

While federal authorities have ramped up enforcement against such crimes in recent years, Florida lawmakers have also taken aim at the problem.

In 2007, lawmakers passed a bill mirroring the Federal False Claims Act that authorizes the state Attorney General’s Medicaid Fraud Control Unit to recover through a civil lawsuit three times the actual damages caused by those who commit Medicaid fraud. In 2008, the Legislature enacted strict licensing and reporting requirements for home healthcare agencies, which have been the source of a significant amount of Medicaid fraud.

In 2009, the Legislature approved a bill that targets home healthcare agencies with tougher Medicaid billing requirements and imposes harsher penalties for those who commit Medicaid fraud. The new regulations elevated Medicaid fraud from a third-degree felony to a first-, second- or third-degree felony based on the amount involved in the fraud. The bill also designated Miami-Dade County as a “healthcare fraud crisis area” for the purposes of increasing the monitoring of home health agencies, home medical equipment providers, clinics and other providers.

The law additionally prohibits the Agency for Health Care Administration from approving new home health agencies in Miami-Dade and Broward counties at least until July. The law also states that AHCA can revoke a home health agency’s license if it demonstrates a “pattern” of billing Medicaid for services that are later deemed unnecessary, with as few as two potential billings constituting a “pattern.”

As Congress contemplates moves toward legislation that could dramatically expand the rolls of Medicaid, and increase potential for fraud, some believe that even more needs to be done.

Craig Smith, a Tallahassee lawyer and health law expert who previously served as general counsel for AHCA, says, “The fundamental change has to be in addressing prepayment prevention. This pay-and-chase system recovers such a small portion of the bad payments.”

Smith likes a pilot program the Florida Legislature passed in 2009 that would require Medicaid to verify telephonically the delivery of home health services using voice biometrics. The program, not yet started, would make committing fraud more difficult, says Smith.

In the book “Stop Paying the Crooks: Solutions to End the Fraud that Threatens Your Healthcare,” Smith says the federal government could do more to weed out cheats by improving the enrollment screening process for applications for new clinics, home health agencies and medical equipment suppliers. Smith also proposes that providers of “very expensive treatments and therapies” be required to meet enhanced prepayment review standards and that public and private payers could improve their information-sharing and coordination efforts to better crack down on fraud.

Tags: Politics & Law, Healthcare

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