On Nov. 12. 2009, the U.S. Department of Justice announced that Kaiser Permanente agreed to pay $1.83 million to resolve certain liabilities under the False Claims Act. The settlement involved hospice claims billed to Medicare by Kaiser Sunnyside Medical Center, Kaiser Foundation Health Plan of the Northwest and Northwest Permanente P.C., Physicians & Surgeons. The claims, billed between October 2000 and March 2004, were made without first obtaining written certifications of the patients' terminal illness required by Medicare. The settlement was the result of a voluntary self-disclosure made to the Department of Health and Human Service's Office of Inspector General in June 2005.
The Medicare regulations require hospice care providers to obtain written certifications of terminal illness (CTIs) for each hospice beneficiary's initial certification period (the first 90 days of care). Those CTIs must be obtained from both the medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) the individual's attending physician, if the beneficiary has one. The CTIs are required, in part, to guard against the provision of medically unnecessary hospice services.
Kaiser Foundation Health Plan of the Northwest issued a statement explaining the measures taken when the problem was discovered internally: "When we first noticed the billing error, we reported it and moved aggressively to improve our handling of paperwork." The written statement continued, "With our voluntary disclosure, we showed our commitment to being a full partner with Medicare in resolving such issues."
There are lessons to be learned from the settlement. Organizations that maintain a robust auditing function as part of their corporate compliance programs are more likely to detect billing problems sooner than those who do not. This in turn allows organizations to rectify billing errors, make proactive disclosures to the government, and thereby minimize the damage that can flow from those errors. Organizations that do not detect billing problems on the front end are at risk of ending up as defendants in a qui tam action or, worse, targets of a wider ranging healthcare fraud investigation and potentially greater penalties.
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