Wednesday, June 12, 2013

Research and Markets: Guide to the Patient-Centered Medical Home: Metrics, Models and Engagement

Published: Monday, Jun. 10, 2013 / Updated: Monday, Jun. 10, 2013 11:21 AM

Research and Markets ( has announced the addition of the "Guide to the Patient-Centered Medical Home: Metrics, Models and Engagement" report to their offering.
The patient-centered medical home (PCMH) has become a hallmark of healthcare delivery. Its team-based model is a mainstay of care coordination for thousands of physician practices that have already transformed themselves into medical homes - many of which are poised to step into an accountable care organization (ACO), according to 2012 market data.
In a nod to the PCMH's potential for improving care and controlling cost, many payors have placed case managers in medical homes to assist with stratification and care coordination of high-risk patients.
Guide to the Patient-Centered Medical Home: Metrics, Models and Engagement provides an overview of PCMH adoption and results and examines nuances of the model that have emerged in recent years - including the embedding of case managers on medical home teams.
Besides a complete set of benchmarks from almost 100 organizations on medical home adoption and program components, HIN's sixth annual PCMH analysis, this 155-page guide offers snapshots of thriving medical home programs, including the following:
- The statewide rollout of Florida Blue's medical home program, from practice selection to reimbursement models;
- The comprehensive PCMH consumer engagement and education effort underway at Horizon Blue Cross Blue Shield of New Jersey to position the Blues plan for accountable care;
- Advice on achieving Level III NCQA medical home recognition, joining an ACO, and participating in the CMS Comprehensive Primary Care initiative from Hunterdon Healthcare;
- Roadmap to the embedding of case managers: Geisinger Health Plan's selection, training, skill set, processes and benefits of case managers embedded within the payor's medical home practices, a model that has become an industry template for co-located case management.
Key Topics Covered:
Chapter 1: 2012 Benchmarks in the Patient-Centered Medical Home
Chapter 2: New Models in the Patient-Centered Medical Home
Chapter 3: The Medical Home Case Manager
For more information visit

12 CA Residents Accused of Attempting to Bilk Medicare of $22 Million Arrested as Part of Nationwide Crackdown


Los Angeles, CA ( - Twelve Los Angeles-area residents—including California’s second-largest biller for chiropractic services, a physician’s assistant, and owners of durable medical equipment (DME) and ambulance companies—were taken into custody today in relation to seven criminal cases that allege they cumulatively submitted more than $22 million in false billings to Medicare.
The charges filed in Los Angeles are part of a nationwide “takedown” by Medicare Fraud Strike Force operations in eight cities that led to charges against 89 individuals for their alleged participation in schemes to collectively submit about $223 million in fraudulent claims to Medicare.
The dozen defendants taken into custody are among 13 people charged in Los Angeles in cases that allege health care fraud. The 12 either were arrested this morning or self-surrendered to authorities after learning that they had been charged in federal court. All those defendants are scheduled to be arraigned this afternoon. A 13th defendant is a fugitive.
Dr. Houshang Pavehzadeh, of the Sylmar Physician Medical Group, allegedly billed Medicare more than $1.7 million for chiropractic treatments he never performed. During the scheme, which ran from 2005 through 2012, Dr. Pavehzadeh, 40, of Agoura Hills, became the second-largest Medicare biller in California for chiropractic services—even though he was not in the United States when some of the alleged services were performed. In addition to being charged with health care fraud, Pavehzadeh is charged with aggravated identity theft related to Medicare beneficiaries whose information he used to bill Medicare as a part of the scheme. When investigators tried to conduct an audit of Pavehzadeh’s claims, he falsely reported to the Los Angeles Police Department that he had been carjacked and that patient files requested by the auditors had been stolen from his car. Pavehzadeh surrendered this morning, and he is scheduled to be arraigned with other Los Angeles-area defendants this afternoon in the Roybal Federal Building.
Nine defendants affiliated with DME companies were also charged in five separate indictments.
Olufunke Fadojutimi, 41, of Carson, a registered nurse; Ayodeji Temitayo Fatunmbi, 41, formerly of Carson and now believed to be residing in Nigeria; and Maritza Velazquez, 40, of Las Vegas, were charged with health care fraud. The scheme allegedly revolved around Lutemi Medical Supplies, a DME company Fadojutimi owned and where Fatunmbi and Velazquez worked. According to the indictment in this case, Lutemi billed Medicare more than $8.3 million in claims, primarily for medically unnecessary power wheelchairs. Fadojutimi and Fatunmbi allegedly laundered Medicare funds in order to purchase fraudulent prescriptions for those power wheelchairs and pay illegal kickbacks to recruit Medicare beneficiaries. Fadojutimi was arrested this morning in Los Angeles, while Velazquez was arrested in Las Vegas. Fatunmbi is currently a fugitive being sought by federal authorities.
Susanna Artsruni, 45, of North Hollywood, and Erasmus Kotey, 76, of Montebello, a licensed physician’s assistant, allegedly worked together to commit health care fraud out of a medical clinic on Vermont Avenue where they both worked. Kotey allegedly prescribed medically unnecessary DME, including power wheelchairs, for Medicare beneficiaries. Many of those power wheelchair prescriptions were then used by Artsruni’s DME company, Midvalley Medical Supply, to support fraudulent claims to Medicare. In only four months, the clinic and Midvalley billed Medicare more than $525,000 for these fraudulent claims. Artsruni has previously been convicted of health care fraud and was on pre-trial supervision at the time she allegedly laundered some of the proceeds of this fraud. Artsruni was arrested this morning, while Kotey self-surrendered.
Three other DME cases were also charged, alleging fraudulent Medicare billing for medically unnecessary power wheelchairs that were sometimes never even delivered. In one case, Akinola Afolabi, 53, of Long Beach, the owner of Emmanuel Medical Supply, allegedly submitted more than $2.6 million in false and fraudulent billing to Medicare. In another case, Queen Anieze-Smith, 52, of Encino, and Abdul King-Garba, 47, of Westwood, the owners and operators of ITC Medical Supply, allegedly submitted more than $1.8 million in false and fraudulent billing to Medicare. In the third case, Clement Etim Aghedo, 53, of Fontana, the owner of Ace Medical Supply Company, allegedly submitted more than $1.8 in false and fraudulent claims to Medicare. Afolabi, Anieze-Smith, and King-Garba were all arrested this morning, while Aghedo self-surrendered.
In the seventh case brought as part of today’s takedown, three defendants affiliated with Gardena-based ProMed Medical Transportation, an ambulance company, were charged with submitting more than $5.9 million in false claims to Medicare between 2008 and 2011. ProMed’s owner, Yaroslav Proshak, 45, of Valley Village; general manager Sharetta Wallace, 35, of Inglewood; and office manager and biller Sergey Mumjian, 40, of West Hollywood, submitted claims for medically unnecessary transportation services and then created fake documentation purporting to support those claims. Proshak, Wallace, and Mumjian were arrested this morning.
The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and the Department of Health and Human Services to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.
The Los Angeles cases announced today are being investigated by a Medicare Fraud Strike Force team, which is composed of agents and investigators with the Federal Bureau of Investigation; the Department of Health and Human Services, Office of Inspector General; IRS-Criminal Investigation; and Medicaid Fraud Control Units, including the California Department of Justice. The cases are being prosecuted by attorneys from the United States Attorney’s Office and the Fraud Section of the Justice Department’s Criminal Division.
An indictment contains allegations that a defendant has committed a crime. Every defendant is presumed innocent until and unless proven guilty.
The charge of health care fraud carries a statutory maximum penalty of 10 years in federal prison. Money laundering carries a potential penalty of 20 years in prison. Aggravated identity theft carries a mandatory two-year prison term.


WellCare executives convicted in fraud trial


Last Modified: Tuesday, June 11, 2013 at 4:46 p.m.

TAMPA, Fla. - Four former WellCare executives have been convicted of some, but not all, charges following a Medicaid fraud trial in Florida.
WellCare CEO Todd Farha, WellCare CFO Paul Behrens, Harmony Behavioral Health vice president William Kale and vice president of operations Peter Clay all faced multiple counts of medical fraud, conspiracy and making false statements. But after several weeks of deliberations, jurors in Tampa told U.S. District Judge James Moody on Monday that they were unable to reach verdicts for the more serious charge of conspiracy to commit medical fraud on each defendant.
Farha was found guilty of two counts of health care fraud, and acquitted of six other charges including giving false statements. Behrens also was found guilty of two counts of health care fraud and two counts of making false statements, but was acquitted of other two other false statement charges. Kale was found guilty of two counts of health care fraud and Clay was found guilty of two counts of making false statements.
Prosecutors say they haven't decided whether to retry to deadlocked conspiracy counts.
A sentencing date hasn't been set. On each of the health care fraud counts, Farha, Behrens and Kale face up to 10 years in prison. The other charges carry a maximum of five years.
Prosecutors say the four men defrauded the government out of more than $30 million. Dealing exclusively with Medicare and Medicaid claims, authorities say the executives produced false documents and formed Harmony Behavioral as a "shell company" to inflate the costs for behavioral health-care services.
Defense attorneys say the expenses were legitimate. They say the state knew about the arrangement but failed to give WellCare and other companies any guidance. They accused federal prosecutors turning a contractual dispute into a federal crime.