TeamHealth Holdings has settled a Medicare and Medicaid fraud lawsuit for $60 million plus interest.

TeamHealth Holdings is a successor in interest to IPC Health Inc. IPC Healthcare was previously named IPC The Hospitalists Inc. It is a national physician group for hospitalists who are doctors who see patients while they are hospitalized.

Whistleblower Reveals Medicare and Medicaid Fraud

A hospitalist who previously worked at IPC Healthcare filed a whistleblower case, shedding light on the alleged Medicare and Medicaid fraud.

At issue is an illegal and unethical practice known as up-coding, which means claims are sent to government agencies for reimbursement for services that are more expensive than the services that were actually performed.

The doctor who filed the whistleblower complaint said that IPC allegedly “knowingly and systematically encouraged false billings by its hospitalists.”

The business went so far as to tell the physicians who billed for less expensive procedures with a lower claim reimbursement rate that they needed to ratchet up their numbers.

TeamHealth is signing a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of the Inspector General, which intends to closely monitor the medication department. The agreement is meant to help TeamHealth prevent and halt potential future attempts at fraud.

In addition to alleged Medicare and Medicaid fraud, IPC up-coded claims also were sent to the Defense Health Agency and the Federal Employees Health Benefits Program.

Medicare and Medicaid Fraud Ring Busted

For nearly 10 years, a Medicare and Medicaid fraud ring sent more than $70 million in false medical bills and collected nearly $25 million in claims reimbursements.

A healthcare clinic manager in New York pled guilty for the part he played in the fraud scheme that involved three New York City healthcare clinics.

From 2005 to 2014, Eduard Zavalunov and eight other people who have pled guilty approached people who were down on their luck and asked the people to undergo medical tests for cash. Employees called “runners” usually found their patient recruits in soup kitchens and welfare offices.

The runners instructed the patient recruits to claim certain maladies as they filled out clinic paperwork in order to justify medical tests.

Prior to running the tests, the fraud ring verified Medicare and Medicaid coverage for the recruited patients to ensure the fraudulent claims would go through properly and that the clinic would obtain subsequent reimbursement.

Sleep tests and stress tests were among the most common fraudulently ordered examinations. Adding to the Medicare and Medicaid fraud claims was the fact that staff who performed tests were not doctors. Both Medicare and Medicaid require that a doctor administer the care as a condition of reimbursement.

The healthcare clinic’s owners allegedly went so far as to pay a licensed doctor to pretend to be the clinic owner and to be the doctor who purportedly was running the tests.

The wrongdoers in the healthcare fraud case could go to prison for up to 20 years and face fines up to $250,000 or double the gross gain or loss that resulted from their near decade-long scam.

If you are aware of Medicare and Medicaid fraud at your place of business or previous place of business, you could file a whistleblower complaint and help stop the ongoing schemes.