Health Law Blog - Healthcare Legal Issues

Posts Tagged ‘Repayment’

RAT-STATS – What Is Rat-Stats?

Tuesday, March 11th, 2014

RAT-STATS and Statistical Estimation of Overpayments

 

rat-stats statistical samplingRAT-STATS is a free software that is offered by the federal government to assist health care providers with statistical sampling.  Statistical sampling models can be used by health care providers to statistically estimate required overpayments based upon a statistically valid sample.  The RAT-STATS package was developed by the Office of Inspector General to assist providers with random sampling.

The RAT-STATS software suite helps make the random sampling process much easier for providers.  Generally, the RAT-STATS can be used to run a small number of claims in an initial probe audit.  The probe audit will suggest whether problems might exist with a defined, randomly selected parameter of claims.  The sample size estimator function will provide sample sizes for complete audits that can statistically extrapolate findings to estimate overpayments within a range of statistical accuracy.

If used properly, RAT-STATS can assist providers in the performance of defined area audits.  Based on identified problems, RAT-STATS can suggest the scope of further, more statistically reliable audit samples.  Based on the results of more complete audit, RAT-STATS can help estimate overpayments.

RAT-STATS is only a tool to help with statistical projection.  Judgment is required in the identification of risk areas that may require monitoring and auditing.  RAT-STATS can be a useful tool for providers to effectuate their compliance efforts.

False Claims Act Basics – Health Care False Claims

Thursday, February 6th, 2014

False Claims Act Basics

Overpayment Repayment 60 Day RuleThe False Claims Act (“FCA”) provides a very strong enforcement tool to the federal government.  The FCA also provides the opportunity for whistleblowers to bring “qui tam” cases and collect a portion of the recovery where false claims are proved against the federal government.

FCA recovery was originally intended to provide a remedy against unscrupulous civil war profiteers.  Penalties were enhanced when the FCA was dragged off the shelf in the 1980s in reaction to some of the overpricing of government contracts selling supplies to the federal government.

Recently, the FCA has become one of the government’s prime enforcement tools t o deter fraud in the federal health care programs.  Historically, the FCA has been available when a health care provider falsely bills for covered services.  Triple damages and an $11,000 per claim penalty provide a strong deterrent in an industry that may make hundreds of claims per day.

Recent legislation has expanded FCA liability to claims that the provider knows resulted in an overpayment if the provider does not make repayment within 60 days of obtaining knowledge of the wrongfully billed amount.  Some of the potential applications of this that makes a simple overpayment a false claim has generated much discussion among health care lawyers and compliance officers alike.  When an organization is deemed to have knowledge of the overpayment has been the subject of much speculation due to the ambiguities that exist in the new rule.

It may be helpful to frame this discussion by touching on the general requirements that must be met in order to prove any claim under the Federal False Claims Act.  The three general elements that must be proved include:

1.         The submission of a claim to the federal government.  In the health care context, the claim will normally be submitted to a government health program.

2.         The claim must be false.

3.         The claim must have been submitted knowingly.  Actual knowledge that the claim was false will always prove the knowledge requirement.  However, a FCA case can also be built around the submission of a claim with “reckless disregard” for its truth or falsity.

Recent health care legislation, in particular the Fraud Enforcement Recovery Act of 2009, greatly expanded the scope of the FCA.  The FCA is now applicable to a wide variety of situations that would not have previously been covered.  For example, the failure to return an identified overpayment now becomes a false claim.  The potential remedies that a provider may face for not promptly repaying known overpayments creates a strong incentive for health care providers to monitor and audit their claims and set up processes that will catch improper billing that could ripen into the FCA.

Reckless disregard or hiding your head in the sand like an ostrich is no longer a way to avoid massive potential FCA liability.

Compliance programs need to be amended appropriately to address the new potential legal and financial risk presented by these new penalties.

False Claims Act Liability For Failure To Repay Overpayment

Wednesday, May 22nd, 2013

False Claims Act Basics – Known Overpayment Become False Claims

overpayment false claims act liability 60 dayThe False Claims Act (“FCA”) provides a very strong enforcement tool to the federal government. The FCA also provides the opportunity for whistleblowers to bring “qui tam” cases and collect a portion of the recovery where false claims are proved against the federal government.

FCA recovery was originally intended to provide a remedy against unscrupulous civil war profiteers. Penalties were enhanced when the FCA was dragged off the shelf in the 1980s in reaction to some of the overpricing of government contracts selling supplies to the federal government.

Recently, the FCA has become one of the government’s prime enforcement tools t o deter fraud in the federal health care programs. Historically, the FCA has been available when a health care provider falsely bills for covered services. Triple damages and an $11,000 per claim penalty provide a strong deterrent in an industry that may make hundreds of claims per day.

Recent legislation has expanded FCA liability to claims that the provider knows resulted in an overpayment if the provider does not make repayment within 60 days of obtaining knowledge of the wrongfully billed amount. Some of the potential applications of this that makes a simple overpayment a false claim has generated much discussion among health care lawyers and compliance officers alike. When an organization is deemed to have knowledge of the overpayment has been the subject of much speculation due to the ambiguities that exist in the new rule.

It may be helpful to frame this discussion by touching on the general requirements that must be met in order to prove any claim under the Federal False Claims Act. The three general elements that must be proved include:

1. The submission of a claim to the federal government. In the health care context, the claim will normally be submitted to a government health program.

2. The claim must be false.

3. The claim must have been submitted knowingly. Actual knowledge that the claim was false will always prove the knowledge requirement. However, a FCA case can also be built around the submission of a claim with “reckless disregard” for its truth or falsity.

Recent health care legislation, in particular the Fraud Enforcement Recovery Act of 2009, greatly expanded the scope of the FCA. The FCA is now applicable to a wide variety of situations that would not have previously been covered. For example, the failure to return an identified overpayment now becomes a false claim. The potential remedies that a provider may face for not promptly repaying known overpayments creates a strong incentive for health care providers to monitor and audit their claims and set up processes that will catch improper billing that could ripen into the FCA.

Reckless disregard or hiding your head in the sand like an ostrich is no longer a way to avoid massive potential FCA liability.

Compliance programs need to be amended appropriately to address the new potential legal and financial risk presented by these new penalties.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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