A Massachusetts hospital recently settled a federal lawsuit over allegations that it billed Medicare and Medicaid for medically unnecessary tests.
But to many, tests like these may seem easy to order accidentally or without knowing they could be medically unnecessary. That is, a good-faith error may mean unnecessary tests and it is common for medical providers to pay the fines without a fight.
Whistleblowers encouraged to step forward
The lawsuit first came from a patient who filed it under the whistleblower “qui tam” provisions of the False Claims Act. This act allows private-citizen whistleblowers to report fraud against federal programs.
“Qui tam” is short for a Latin phrase suggesting someone is filing suit on behalf of the king as well as themselves.
When qui tam whistleblower cases succeed, the government gets most of the money recovered and as a reward in many cases, the whistleblower stands to get 15% to 30% of the total recovered.
In this case, the hospital will pay more than $11,000 to resolve the case.
Tests for ticks not found in Massachusetts
The Massachusetts case involves testing panels the hospital used to test patients for tick-borne diseases.
The panels included tests for diseases that ticks probably would not transmit in the ranges (geographic areas) where the patient suffered bites, the suit says.
It also alleges the patients did not show symptoms for those diseases. The facts, therefore, did not medically indicate some of the tests in the panels and the claims submitted to Medicare and Medicaid requested payment for medically unnecessary blood tests, according to the suit.
Overpayments require quick action and ready expertise
The Affordable Care Act rules for identifying and returning overpayments, including the “60-Day Rule,” are strict and do not allow much time to review what happened and why.
Penalties for not acting on time become more complex and severe even more quickly, often leading to quick settlements regardless of whether the outcome is just.