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Cal Stein, a partner in Troutman Pepper’s White Collar + Government Investigations Practice Group, was quoted in the April 19, 2023 Managed Healthcare Executive article, “For Fraudsters, COVID-19 Is the Sound of Opportunity Knocking.”
CMS enacted COVID-19 testing guidance and regulations, with payments sometimes made to noncontracted laboratories, notes Callan Stein, J.D., a partner with Troutman Pepper, a law firm in Boston. “The government did it out of necessity with a mandate to increase testing access.” But that opened the door to new providers, some of them swindlers.
[…]
To identify potential fraud, the government may look at the raw volume of telehealth visits and average number of hours and days billed. Telehealth providers with high volumes should pay attention to compliance and the medical necessity of all visits, Stein says.
[…]
Federal regulators use data analytics to comb through billing claims and identify patterns, Stein says. “Just because the pattern exists, doesn’t mean there’s fraud,” he says.Practices with legitimate billing patterns outside the norm should be careful about documentation and check that services met medical necessity threshold.
[…]
Government fraud cases, including kick-back allegations, require intent, Stein says. “In my experience, there’s usually not intent. Usually, we’re dealing with conflicting interpretation of complex and sometimes confusing regulations and good faith or differing opinions on how a CPT (Current Procedural Terminology)code ought to be applied,” Stein says. If one particular code is frequently used incorrectly, that mistake could be repeated hundreds or thousands of times.
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