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Atlanta Outlier Payments Attorney

Medicare Part A pays for inpatient stays at hospitals. To encourage hospitals to provide efficient care, Medicare will only reimburse using a flat fee instead of an itemized bill. This strategy has worked well, forcing hospitals to find ways to save money while still providing high level care.

However, Medicare also realizes that some patients require very costly treatments, and the government doesn’t want to bankrupt hospitals or discourage them from providing this expensive care when it could prolong life. For that reason, the government will also make certain supplemental payments, called “outlier payments.” The hospital indicates it wants to receive an outlier payment when it submits its UB-92 form to Medicare.

As you can imagine, the outlier payment system does create opportunities for fraud.

How Hospitals Commit Outlier Payments Fraud

The foundation of this type of fraud involves classifying a patient as much sicker than they really are. The hospital then provides unnecessary, expensive medical care or, just as likely, doesn’t provide any extra care but bills for it. Many people in the hospital are involved in this type of scam, which often involves changing patient records to suggest the patient was very ill when that was simply not the case.

Outlier payments fraud is very difficult to detect. Admittedly, Medicare can perform audits of hospital cost reports. But they have a backlog of cases and lack the staff to carefully comb through all records. Patients might not even see their patient records, which classify them as sicker than they were, so they have no idea fraud was committed.

Nevertheless, outlier payments can make up a large percentage of the reimbursements hospitals receive from Medicare. For example, one study in 2013 found that outlier payments were 12% of reimbursements at more than 100 hospitals across the country. The government would very much appreciate receiving evidence of outlier payments fraud so they can crack down on illegal payments.

Contact Stacey Evans with Evidence of Outlier Payments Fraud

The Office of Inspector General is tasked with investigating fraud. Whistleblowers who have evidence of outlier payments fraud have options for shining a light on this illegal conduct. For example, you can report suspected fraud using a tip line.

Alternatively, those with evidence of fraud can file a lawsuit under the False Claims Act. This federal law makes it illegal to submit fraudulent claims to the government, including Medicare. The purpose of the lawsuit is to force the hospital to pay back reimbursements received for fraudulent submissions. Once filed, the government can intervene in the suit and take it over. Those bringing these types of suits can receive a portion of the money recovered.

Free Consultation with an Atlanta Outlier Payments Attorney

Stacey Evans Law is an established law firm in Atlanta that handles medical fraud cases, especially those involving fraudulent Medicare claims. To learn more about whether you should blow the whistle, contact our firm today to schedule a free, no-risk consultation call with a member of our legal team.

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