Massive billing schemes found at rural hospitals - Entrepreneur Generations

After the recent revelation of massive billing schemes at some rural hospitals, insurance companies are trying to get back nearly half a billion dollars they paid to rural hospitals throughout the country in similar schemes. "In March, Blue Cross Blue Shield filed a $60 million lawsuit against Hospital Partners, alleging their arrangement with labs was a 'fraudulent scheme,'" Jim Axelrod reports for CBS News. Hospital Partners is in turn suing Missouri state auditor Nicole Galloway, claiming she had no right to audit Hospital Partners property Putnam County Memorial Hospital in 2016.

The scheme works like this: a company that owns a laboratory service (such as Hospital Partners) buys a struggling rural hospital, then issues bills for laboratory work from all over the country from the rural hospital. This means more profit for the lab because insurance companies reimburse rural hospitals at higher rates to help keep healthcare in those areas. The labs sometimes plump their bottom lines by paying kickbacks to healthcare providers for specimens they could then bill at the higher reimbursement rates, Axelrod reports. "Essentially the hospital appeared to act as a shell company for these questionable lab billings," Galloway said. "In a six-month period, [Putnam] funneled through about $92 million in revenues. To put that in perspective, the previous year their total revenues were $7.5 million."

Jason Mehta, a former federal prosecutor who specialized in healthcare fraud, told Axelrod that defining the scheme as fraud requires specific parameters: "The question's gonna be did the laboratories intend to cheat? Did they intend to trick? Did they mislead the insurance companies? Because simply making extra money isn't a crime in and of itself. It's the question of, was someone tricked? Was some deceived?"

from The Rural Blog https://ift.tt/2wOmfTg Massive billing schemes found at rural hospitals - Entrepreneur Generations

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