Health care providers have often thought that if they are not billing Medicare or Medi-Cal, they will not be the subject of federal investigation. Now that private insurance is subsidized by the government for low income individuals, there is a significant push to investigate these cases. In addition, private insurance companies are submitting the cases for prosecution. One recent case shows what these cases can look like. It also show that coding matters and claim submissions if not accurate can lead to fraud allegations.
On March 7, 2019, a federal grand jury indicted San Francisco acupuncturist Haichao Huang, charging him with
health care fraud and making false statements relating to health care matters. An indictment is not evidence and Mr. Huang is presumed innocent.
According
to the indictment, the government alleges that from February 2013
through June 2018, Mr. Huang, age 46, was a health care provider who
offered acupuncture, physical therapy, massage, and other services at his
office in San Francisco. The indictment alleges that Mr. Huang submitted
claims for reimbursement to his patients’ health insurance plans, claiming that
he provided reimbursable services and treatments when, in fact, he knew that
the billings were false and not properly reimbursable.
The indictment
gives three examples of the ways in which Huang allegedly submitted billings
for reimbursement. First, Mr. Huang allegedly submitted requests for reimbursement for
acupuncture and other treatments when, in fact, the patient had received either
much shorter periods of treatment or no treatment at all. This could be an upcoding situation or what is called "ghost billing" (billing for service that was not provided).
Second, after a
patient reached the limit of acupuncture sessions allowed by the relevant
insurance plan, Mr. Huang allegedly billed the plan for other types of treatments and
services that were not provided in order to continue receiving improper
reimbursements.
Providers need to be careful not to try to "help" the patient by giving them covered services when their coverage has run out. I have seen patients ask providers to bill their spouse's or children's insurance when limits were hit. Health care providers are in a helping profession and sometimes have a hard time saying "no." I advise my clients to use humor ("well, who will be your acupuncturist when I'm in jail?") or blame me ("my lawyer will kill me if I do anything like this since she believes in bad luck and this just isn't worth it...maybe we can do some reduced charges if you have a financial hardship."
Third, Huang submitted claims for services rendered on
days when the patient beneficiaries were not seen and received no services at
all—including days when Mr. Huang was not in California. Situations like this can happen if a provider uses an associate who bills under their NPI or UPIN number and has not added them to the group. It can also happen when patients try to get the provider to not bill for copays and ask them to bill for visits that did not occur in order to make it even. Providers need to be very careful about any of these situations.
In sum, Mr. Huang
is charged with six counts of health care fraud, in violation of 18 U.S.C. §
1347, and one count of false statement relating to health care matters, in
violation of 18 U.S.C. § 1035(a)(2). This is a joint federal and state prosecution resulting from investigations by
the Office of Personnel Management Office of Inspector General and the
Department of Labor Office of Inspector General, with assistance from the San
Mateo County District Attorney’s Office.
I cannot recommend enough having a compliance plan for billing private insurance and government insurance. It will keep charges from being criminal. It is a safe harbor and keeps a provider in the civil and administrative overpayment areas. It is not that expensive to do it and should be considered as important as liability insurance.
Posted by Tracy Green, Esq.
Office: 213-233-2260
