• Don’t Get Caught in Un-“charted” Territory — Prevent FCA Claims with Better Medical Documentation
  • May 3, 2017 | Author: Rocklan "Rocky" William King
  • Law Firm: Adams and Reese LLP - Nashville Office
  • Healthcare fraud and abuse claims under the False Claims Act are on the rise, with the United States Department of Justice boasting that it recovered $2.5 billion in settlements and judgments in healthcare fraud investigations, prosecutions and civil litigations in 2016.

    President Trump has committed to continue the fight against fraud and abuse and there is no sign that the DOJ will slow down in its efforts to combat false claims in the health care industry in 2017. A federal jury recently found that Sea Crest Health Care Management LLC, and other affiliated long term care facilities, violated the FCA when they submitted medical claims for reimbursement that were not medically necessary. The government alleged, and the jury concluded, the care documented by Sea Crest in the patient’s medical charts did not support the reimbursement claims that Sea Crest submitted. Once penalties and fines were included, the judgment exceeded $300,000,000, a potentially devastating sum.

    The Sea Crest litigation is only the most recent cautionary tale regarding the consequence of poor medical charting. Health insurance companies, Medicare and state Medicaid organizations have stepped up auditing of medical charts. As the primary tool providers use to document a patient’s health condition, treatments received, and responses to that treatment, chart contents must support the medical reimbursement claims submitted for a patient’s treatment.

    If the care is not properly documented, these entities may deem the prior medical claim improperly paid and demand repayment by either seeking immediate repayment or using recoupment to offset the payment of future claims. As such, poor charting can result in the loss of operating income.

    In more extreme circumstances, poor charting can result in allegations of fraudulent or abusive billing practices, as was the case for Sea Crest. Such a conclusion can result in cataclysmic consequences for health care entities. The FCA provides for statutory penalties of $11,000 per claim, plus three times the amount of damages which the federal government sustains because of the false claim.

    Thankfully, all this can be avoided. Focusing on good charting practices, such as identifying the care provided and the justification for that care coupled with good communications with your practice's billing coordinators can often alleviate billing mistakes. Further, internal audits of billing practices by in-house or outside counsel can help determine if billing practices need to be adjusted.