Government getting tough on abuses
The Clinton administration’s proposed legislation on health care fraud covers a wide range of abuses. Here are the highlights:
• Requires providers to bill the government at the reimbursement rate applicable to where the service is provided, not where the company is headquartered.
Home health agencies, hospices, and other providers sometimes establish headquarters in an area that allows higher reimbursement than where their patients are treated.
• Bars all kickbacks to doctors for referring patients to specialists.
This would not be a new law, but an expansion of existing laws.
• Eliminates "gateway services" that allow fraudulent charges in home health.
Current laws allow providers to use an inexpensive service as a way to get into the home for more expensive services. The patient may need blood drawn, a legitimate Medicare expense, and that makes the patient eligible for other more expensive services that, by themselves, would not be reimbursable.
• Establishes a national program for collecting data.
The federal government has not carried out laws passed in 1996 and 1987 that were designed to exclude unscrupulous doctors from Medicare, Medicaid, and other federally funded health care programs, according to a report by June Gibbs Brown, inspector general of the Department of Health and Human Services in Washington, DC. The 1996 law required the Secretary of Health and Human Services to establish a data collection program for the reporting of final adverse actions against health care providers. In announcing the push to find fraud, President Clinton said the administration would act quickly to create the database.
• Requires doctors and others to provide a Social Security number.
This would close a major loophole that allows physicians, home health agencies and others to participate in Medicare and Medicaid by changing the name of their businesses after being expelled.
• Makes it more difficult to avoid penalties by declaring bankruptcy.
The Clinton administration sees this as another loophole that allows providers to skip out on their fines and penalties by declaring bankruptcy, then opening a business under another name.
• Attaches a lasting stigma to expulsion from Medicare or Medicaid.
Hospitals and other organizations would be barred from hiring anyone who has been expelled from the federal health care programs for misconduct until that person has been reinstated. Health care providers would be expelled for a minimum of six months, and reinstatement would not be possible until they corrected the problems that led to the expulsion.
• Expels health care providers convicted of felonies.
Expulsion would be possible even if the felony had nothing to do with health care.
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