Federal investigators are watching wound care billing practices closely because Medicare and Medicaid costs linked to debridement, wound repair, and skin substitutes have risen in recent years. Providers who bill these services need to know that the Office of Inspector General (OIG) and the Department of Justice (DOJ) are reviewing these claims more often, especially after the recent Arizona case involving more than $1.2 billion in fraudulent billing.
Healthcare professionals who believe improper claims are being submitted can report those concerns through a health care fraud lawyer. Enforcement in the skin substitute market remains one of the Department of Justice and Office of the Inspector General’s highest priorities.
Why OIG is examining wound care and Medicare Part B claims
OIG’s recent Data Snapshot shows that Medicare Part B spending for skin substitutes in non-facility settings has risen faster than expected. That category includes in-home wound care and other outpatient services. When combined with hospital and skilled nursing facility care, the total national cost is even higher.
OIG highlighted several patterns that raise concerns:
- New providers who bill almost no services besides skin substitutes
- Skin substitutes billed during first visits without evidence of prior treatment
- A rapid rise in supply prices
- Higher costs for certain in-home wound care services
- Increasing use of skin substitutes when other options may meet the patient’s needs
These patterns suggest conditions where fraud can develop, especially in high-volume outpatient settings. The payment structure for Medicare Part B has made these services more vulnerable because reimbursement for skin substitutes has historically been higher than for other methods of wound care. When spending rises quickly, investigators focus on whether the care was medically appropriate or billed in an accurate way.
Why Medicare Part B is especially vulnerable to fraud
Medicare Part B reimbursement rules have sometimes favored the use of skin substitutes, and that payment structure can influence how certain providers approach wound care. Fraud occurs when a provider bills for services that were unnecessary or not provided. Investigators have seen cases where skin substitutes were used when simpler treatments may have met the patient’s needs.
OIG and DOJ reports also describe situations where extensive wound care services were billed for hospice patients who were already receiving comfort-focused care. When those services do not match the patient’s treatment plan, the claims may raise questions about medical necessity.
The government has launched several enforcement actions in response to these concerns. Some cases have resulted in significant penalties and prison sentences. Medicare has also shifted toward more standardized payment rates for many skin substitutes to reduce opportunities for inflated billing.
Experienced, Nationwide Representation
Our experienced legal team–both in skin substitute investigations and as former federal prosectors–make us a formidable advocate for you or your business. We represent clients nationwide.
Griffin Durham Tanner & Clarkson LLC represents both companies and individuals involved in OIG or DOJ investigations. The firm helps clients evaluate potential issues, understand their obligations, and respond to government inquiries. Contact us online to speak with an attorney. Give us a call at (404) 891-9150.
