Audit Discovers Nearly $80 Million in Medicare Ventilator Fraud

Ventilator treatment is intense and expensive. Not surprisingly, Medicare has strict rules regarding reimbursement when a hospital reports ventilator use. Over a six-year period, Medicare paid approximately $3.6 billion to hospitals in response to Medicare codes stating that the patient had been on a ventilator for at least four days (96 hours). When a review of records indicated that some of the individuals had not even been in the hospital for four days, that prompted the Office of the Inspector General (OIG) for the Department of Health and Human Services to conduct an audit.

Based on a sampling of 250 cases where beneficiaries were hospitalized for between five and 10 days, the (OIG) calculated that incorrect coding triggered substantial overpayment to medical facilities. Extrapolated over the full body of matters where these codes were used, the OIG estimated $79.4 million in improper payments over the audit period. 

Payments to facilities under the system are based on Medicare Severity-Diagnosis Related Groups (MS-DRGs). When claims are filed relating to ventilator use, the start date is documented, but not the date that the patient was taken off the ventilator. Of the 250 claims analyzed where coding indicated 96 hours or more of mechanical ventilator use, eight involved situations where the treatment lasted fewer than 96 hours. In nine other claims, there was no corresponding procedure code associated with the diagnosis code. 

The findings of the OIG audit show that even simple forms of misconduct, such as misstating the number of days a hospital patient was on a hospital ventilator, can give rise to millions of dollars in Medicare fraud. Complex misrepresentations regarding scientific data and deceptive MS-DRGs can be even more difficult to detect. That’s why honest workers willing to report fraudulent activity are so important within the healthcare industry. 

No matter what role you serve in the medical field, you could run across coding errors, factual misrepresentations or other unlawful actions designed to collect excessive payments from government programs such as Medicare and Medicaid. If this is the case, it’s time to speak with an attorney who can explain the protections you have as a whistleblower and advise if you might be able to collect a financial award for reporting fraud to the government. At Kardell Law Group, we are strong advocates for whistleblowers in cases stemming from Medicare fraud and other illegal methods of obtaining government funds.