Medicare Fraud Enforcement Efforts Are Rising in Texas

xray fraud gavel

(October 27, 2015): Over the past year, Medicare fraud enforcement efforts throughout Texas have resulted in multiple convictions.  These increased enforcement efforts should serve as a reminder to all Texas health care providers and suppliers that full compliance with applicable statutory and regulatory requirements is not an option -- it is a necessity.

I. Medicare Fraud Enforcement Efforts are Accelerating in Texas:

In Houston earlier this year, one couple pled guilty to Medicare fraud and Medicaid fraud out of more than $9 million dollars. The owner was alleged to have violated the federal Anti-Kickback Statute by paying Medicare beneficiaries to visit the clinic and also billed for services that were supposedly never performed, despite the fact that they were billed to Medicare and Medicaid.  The owner’s wife, a registered nurse who ran the clinic, was convicted of misprision (knowing concealment) of a felony.  The couple also agreed to pay restitution to Medicare and Medicaid as part of their plea agreements.

A recent ambulance Medicare fraud case out of the Rio Grande Valley was prosecuted against the owner of the company alleging that documentation had been forged and that hundreds of thousands of dollars worth of false claims had been billed to the Medicare and Medicaid programs.  In addition to charging the defendant with charged with conspiracy to commit health care fraud, he was also charged with aggravated identity theft.

In another fairly recent example of fraud, a Gulf Coast physician practice entered into a settlement with the Department of Health and Human Services, Office of Inspector General (HHS-OIG) for allegedly submitting medical claims for services that were performed by unqualified technicians.

II. Exclusions are on the Rise:

The improper employment of "excluded" parties are another hot area of litigation you should consider. Last year, the general partner if a multi-facility set of skilled nursing homes was penalized for employing individuals who had been previously excluded from participation in federal health benefit care programs. The sad part is these violations were not only expensive, but also completely preventable. Providers should be acutely aware that government enforcement efforts are increasingly turning to Permissive Exclusion under the Social Security Act, where HHS-OIG has wide discretion to bar participants from federally funded programs from 1 to 5 years. Reinstatement cannot be requested until the exclusion term is completed. Each program must be reapplied for individually and could take another 6-12 months to receive the paperwork and complete, making the effective term 18-24 months. Further, every state, including Texas, has its’ own exclusionary statutes that must be complied with for purposes of re-enrollment in Medicare or Medicaid. State law cannot do less than federal law, but it could be even more restrictive, such as the Texas HIPAA law.

III. Checking the Exclusion Lists – Just Do It:

The simplest and most effective thing you can do to protect your healthcare practice or business is to check the exclusion lists religiously. Texas requires that exclusion lists to be checked on a monthly basis. Checking the exclusions list on a monthly basis may not be easy, but it is required. For larger entities it can also be costly and time consuming.  Nevertheless, it must be regarded as part of the essential cost of running your health care business.  Need exclusion screening assistance, check out one of the many vendors who provide these services.  Personally, I recommend you check out the services offered by "Exclusion Screening LLC" at  The company was started by Robert W. Liles and Paul Weidenfeld, two colleagues of mine. It simply has to be done, not only to be in compliance with federal and state law, but to prevent the risks and much more expensive penalties associated with the filing of false or tainted claims by these individuals. The result could not only lead to extremely large overpayments, but unnecessarily risk your exclusion from all federally funded programs, as well.

Pecore, Richard
Richard Pecore, Esq., serves as an Associate at Liles Parker, Attorneys & Counselors at Law.  Liles Parker attorneys represent health care providers and suppliers around the country in connection with Medicare audits by RACs, ZPICs and other CMS-engaged specialty contractors.  The firm also represents health care providers and medical billers in regulatory compliance reviews, HIPAA Omnibus Rule risk assessments, privacy breach matters, and State Medical Board inquiries.  For a free consultation, call Robert at: 1 (800) 475-1906