9/13/2023 0 Comments Nova medical center lawsuit![]() ![]() ![]() Estimates show that fraud accounts for approximately 10% of the property and casualty industry’s incurred losses and 3% to 10% of private and public medical care expenditures - the impact reaches far beyond workers’ compensation. ![]() However, insurance companies also must protect themselves against provider-architected schemes. Claimant-driven fraud remains a risk worthy of traditional surveillance work and rules-based checks. Medical providers (not claimants) are a major fraud driverĪccording to Texas Mutual, medical provider fraud “pack a harder financial punch” (See Licenseįor Use of Current Procedural Terminology, Fourth Edition, Centers for Medicare & Medicaid Services.) The difference that the provider can bill, when extrapolated over thousands or tens of thousands of claims, can drive millions in incrementalĪ one-on-one code also can be billed multiple times because the dollar amount is per 15-minute increments, while the group therapy code is “untimed,” and as such would be billed only once per visit. Subtle - consider that the current procedural terminology (CPT) code for “therapeutic exercises,” 97110, has a national average of $31.35 while the CPT code for “group therapeutic procedures,” 97150, has a national average of $18.74. In the Nova case, the distortion of truth occurred when Nova upcoded therapeutic procedures and exercises, and submitted claims to Texas Mutual Insurance for one-on-one encounters that were actually done in a group setting. Out of an entity paying for the injured worker’s care. Soft fraud occurs when a medical provider milks additional dollars ![]() The operative word in the soft fraud definition is “legitimate,” which in this context could mean there’s an actual injured employee who did, in fact, receive some sort of medical care. Third, how insurance companies use (or don’t use) data can have a significant impact on their ability to take a proactive versus reactive stance to fraud. Second, it underscores the magnitude of fraud at the provider entity level examples of individual employees defrauding the workers compensation system often make the news, but medical provider fraud tends to have a larger dollar impact even if it occurs “opportunistic fraud, occur when people pad legitimate claims.”) Nova didn’t conjure up patient visits or otherwise outright fabricate insurance claims submitted to Texas Mutual, but they did materially misrepresent the nature of care provided. This case is a significant reference point of medicalįirst, the nature of the infraction falls under the amorphous category of “soft fraud.” (Defined by the Insurance Information Institute as Management (also known as Nova Medical Centers or Nova) overbilled Texas Mutual for physical therapy by billing services as more expensive one-on-one therapy when it actually provided group therapy. (See Major Medical Chain Pleads Guilty, Repays Texas Mutual $6.5 Million, Texas Mutual Insurance Company, by Terry Frakes.) The investigation revealed that Nova Healthcare 10, 2015, Nova Healthcare Management pleaded guilty to felonious workers’ compensation fraud and agreed to repay Texas Mutual Insurance Company more than $6 million. ![]()
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