Freedom Health has denied any wrongdoing. “We have agreed to resolve contentious claims without authorization of liability to avoid delays and the cost of litigation, so that we can focus on providing quality care, member service and maintaining the highest Medicare Star ratings,” Bijal Patel, corporate advisor for Freedom Health and Optimum HealthCare, said in a statement. Recently, Gilead Sciences, Inc. entered into a settlement agreement with the U.S. Department of Justice (DOJ) to clarify allegations that it violated the False Claims Act by illegally using a foundation as a channel to pay supplements to thousands of Medicare patients. Put monitoring and surveillance controls in place. The Compliance Department should oversee donations to independent charitable PAPs each year by adopting both a risk-based approach to targeting and a random approach to sampling. The documentation to be reviewed includes budget documents; Documents relating to the donation decision-making process; and all written agreements, as well as any communication and interaction between the company and the independent charity PAP. Consistent with the recent past, the most common legal theory among health care provider institutions was that the provider had billed public health programs for goods or services that were not medically necessary. In many of these cases, medical necessity was the only underlying theory of adherence that reflected the DOJ`s continued focus on issues of medical necessity. DoJ also often makes accusations of medical necessity in larger and more complex allegations of misconduct.
For example, an Arizona-based health organization that owns and operates 28 acute hospitals in several states has agreed to pay more than US$18 million to respond to accusations that 12 of its Arizona and Colorado hospitals “knowingly made false claims to Medicare by allowing patients who could have been treated on a less expensive outpatient basis.”  According to the press release, these 12 hospitals had knowingly overburdened Medicare patients for short-term inpatient stays that should have been billed as outpatients. In addition to these medically unnecessary hospitalizations, hospitals allegedly provided falsified documents to Medicare in their reports by artificially increasing the number of outpatient observation hours received by patients. In addition to the monetary regime, the health organization entered into an enterprise integrity agreement with HHS OIG, which required the company to make “substantial compliance efforts” over the next five years, including maintaining an independent auditing body to verify the accuracy of the company`s rights to Medicaid and Medicare beneficiaries. Compared to the same period of the calendar year 2017, the first half of calendar year 2018 saw an increase in civil fines (“GCM” due to settlement agreements and voluntary self-reports). HHS OIG announced 61 PMCs with a total value of approximately $46 million, an increase of nearly 30% in the number of cases and a 100% increase in total recovery over the first half of calendar year 2017.  In the first half of calendar year 2018, self-reported CMPs accounted for about 86% of the dollar value, with the largest self-billing account being about six times greater than the largest comparison without self-reporting.