On August 1, 2016, the United States Department of Justice (DOJ), through the United States Attorney’s Office, Northern District of New York issued a press release regarding the DOJ’s resolution of fraud allegations against St. Joseph’s Hospital Health Center (St. Joseph’s). No determination of fraud by a Court has been determined nor have the allegations of fraud been proven. Our Georgia healthcare law firm follows legal developments with regard to healthcare reimbursement and fraud and abuse.
The Federal Government’s allegations against St. Joseph concern the state’s Medicaid program. The DOJ alleged that St. Joseph’s staff was not qualified to provide certain mental health services for which Medicaid reimbursement was sought and obtained. St. Joseph provided the services in question under its program known as the Comprehensive Psychiatric Emergency Program (CPEP). The CPEP maintained a mobile unit that would serve patients in particular counties who could not, or would not, access mental health crisis intervention services available in the emergency room. New York law has regulations with which CPEPs must comply. Those State regulations delineate the proper composition of professional staff who must be involved with the applicable intervention services when such services are provided somewhere other than in the emergency room. Reimbursement for such services is expressly conditioned upon compliance with the New York regulations that govern proper staffing.
The DOJ alleged that St. Joseph violated the New York False Claims Act by submitting payment to Medicaid for “mobile-crisis outreach services” by individuals who did not meet New York’s CPEP qualifications to provide such services. The alleged violation of the New York False Claims Act was premised on the submission of claims for payment without disclosing that St. Joseph’s staff (allegedly) failed to meet the qualification requirements under State law for the particular services provided. St. Joseph’s agreed to pay $3.2 million to conclude the matter.
Involved in the investigation and law enforcement efforts of the Federal Government were the United States Attorney’s Office, the New York State Attorney General’s office, and the United States Department of Health and Human Services (HHS) through the Office of the Inspector General (OIG).
The Federal Government continues to make its law enforcement efforts with respect to the various healthcare fraud and abuse laws a top priority for the benefit of patients and Federal taxpayers, as reflected in the DOJ’s February 26, 2016 Press Release. The Federal Government’s arsenal includes the Health Care Fraud Prevention and Enforcement Team (aka “HEAT”) and the following fraud and abuse laws:
The False Claims Act:
- Statute: 31 U.S.C. §§ 3729-3733
The Anti-Kickback Statute:
- Statute: 42 U.S.C. § 1320a-7b(b)
- Safe Harbor Regulations: 42 C.F.R. § 1001.952
The Physician Self-Referral Law
- Statute: 42 U.S.C. § 1395nn
- Regulations: 42 C.F.R. §§ 411.350-.389
The Exclusion Authorities
- Statutes: 42 U.S.C. §§ 1320a-7, 1320c-5
- Regulations: 42 C.F.R. pts. 1001 (OIG) and 1002 (State agencies)
The Civil Monetary Penalties Law
- Statute: 42 U.S.C. § 1320a-7a
- Regulations: 42 C.F.R. pt. 1003
Criminal Health Care Fraud Statute
- Statute: 18 U.S.C. §§ 1347, 1349
*Disclaimer: Thoughts shared here do not constitute legal advice.
Source: DOJ Press Release