Wednesday, June 19, 2013

Michigan Doctor Sentenced for Role in Medicare Fraud Scheme

Department of Justice
Office of Public Affairs
Thursday, June 6, 2013

Lansing-area resident Dr. Paul Kelly was sentenced to 18 months in prison today for his role in a $13.8 million Medicare fraud scheme.
Acting Assistant Attorney General Mythili Raman of the Criminal Division; U.S. Attorney for the Eastern District of Michigan Barbara L. McQuade; Special Agent in Charge Robert D. Foley III of the FBI’s Detroit Field Office; and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services, Office of Inspector General’s (HHS-OIG), Chicago Regional Office, made the announcement.
Kelly, 76, was sentenced by U.S. District Judge Gerald E. Rosen of the Eastern District of Michigan.  In addition to his prison term, Dr. Kelly was sentenced to three years of supervised release and ordered to pay $582,912 in restitution.
Kelly pleaded guilty on Jan. 10, 2013, to one count of health care fraud.  According to information contained in plea documents, beginning in or around January 2011 and continuing through approximately March 2011, Kelly signed home health care referrals for a home health agency called Moonlite Home Care Inc., located in Livonia, Mich. Kelly certified Medicare beneficiaries as homebound, a requirement for receiving home health care, when in fact, Kelly had never examined or met the beneficiaries, and they were not homebound. Medicare paid approximately $582,912 for fraudulent home health care claims submitted by Moonlite based on Kelly's referrals.
This case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Eastern District of Michigan. This case was prosecuted by Trial Attorney Catherine K. Dick of the Criminal Division’s Fraud Section. 
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $5 billion.  In addition, HHS’s Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

The Creative Destruction of the RADV Audit

Kameron Gifford, CPC          6/19/2013

How much does your company spend outsourcing chart audits and education? What if you could “dump” all of those medical records into a program that would identify only the records with deficient or incomplete documentation? What if that same program could then design and build an individualized, interactive mobile platform targeted to those deficiencies? A single secure dashboard that can track and monitor compliance and progress all in one place. What value could this create for the Senior VP managing 17 markets in 6 states or the Managing Director responsible for 91 centers? How could this positively affect provider buy-in and add transparency to risk adjustment initiatives? Ultimately, how much money could this disruptive innovation save your organization?

I am a certified coder, who specializes in risk adjustment coding and clinical documentation improvement. This unique skill comes with its own unique set of challenges. Due to the Government’s recent assault on our industry my services are in great demand. This in itself is great news, except that the current process of auditing is inefficient and redundant.

The “digital” age has completely modified our entire culture. Consumers want more, bigger, faster, better, smarter and all for less money. Technology has transformed and altered society to a point of dependence. We can all relate to that “terrifying moment when we reach for our cell phone and it’s not there. Who would have predicted 20 years ago that this “phone” would replace our alarm clocks, travel agents, mail, books, televisions and computers?

Until recently, the healthcare industry has been isolated, shielded from the chaos of disruptive innovation that has transformed every other industry. But today that separation barley exists, and we are seeing more and more tech companies entering the healthcare space. This collaboration yielded the first electronic medical record and delivered the first computer assisted coding programs. But the healthcare industry has yet to be profoundly touched by any of these inventions.

As an industry, we must take heed to what lies ahead. We must learn from the error of those around us and continually strive for something better. We must promote “the right way” and stop allowing the court system to influence the practice of Medicine in America.
How can we use new technology to assist us in our compliance and due diligence responsibilities in terms of HCC Coding and Documentation? How can we engage and excite our providers? How do we build an “on-demand” teaching system that focuses on improving documentation specific to risk adjustment rules? What if we designed a mobile teaching platform available to all clinicians at the point of care. What value would this add on the back end for auditors and educators as a way to “sort” massive amounts of records and triage providers in order of need? What if the government stopped finding “fraud” and was unable to demand recoupments fines and penalties?

The entire delivery of care as we know it, is about to be disrupted. Contact ERM today to find out how you can be part of it.


ACMC earns health care home certification

WILLMAR - It’s official: Affiliated Community Medical Centers is now certified by the Minnesota Department of Health as a health care home.

The certification applies to all of ACMC’s clinic locations: Benson, Granite Falls, Hancock, Litchfield, Marshall, New London-Spicer, Redwood Falls and Willmar.
A health care home, also known as a patient-centered medical home, is an approach to health care that emphasizes a partnership among primary care providers, patients and families to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities. The health care home also puts patients at the center of care decisions, whether they’re seeking care for common, acute or chronic conditions.
“Our goal has always been to provide the best care possible for our patients,” Dr. Robert Kaiser, a family physician with ACMC, said in a statement. “We are very excited about the concept of medical home. At a time when medicine is becoming increasingly complex and expensive, the need for listening, coordinating patient concerns, tests and specialty care, or just offering practical medical advice is greater than ever.”
Studies on the patient-centered medical home have found people who participate in a health care home tend to have fewer hospitalizations and miss fewer days of work or school. The medical home model may also help reduce the overall cost of care, especially for people with special health care needs.
Chronic unmanaged diseases and unnecessary emergency room visits are thought to account for more than 70 percent of U.S. health care expenses.
The development of health care homes in Minnesota is part of health reform legislation passed in 2008. This model of care also is being developed in medical practices nationwide.

Medicare Fraud Reduction Plan Introduced | Alton Daily News

Medicare Fraud Reduction Plan Introduced

Story by WBGZ Radio

An Illinois congressman is taking another stab at reducing Medicare fraud. U.S. Rep. Peter Roskam (R-Wheaton) has introduced a bill to require the government to sniff out fraud in Medicare and Medicaid the same way credit card companies are alerted to suspicious activity. “It’s literally deploying technology that’s already used. This is not blue sky technology. This is not some brand-new, untried thing, but it is technology that is tried and true, and what we’re saying is it is time for the federal government to adopt this same technology,” he said at a news conference at Northwestern Memorial Hospital in Chicago.
Credit card companies use software that raises red flags if a card holder attempts to make purchases out of the country without having purchased a plane ticket or a hotel stay there, for example, or if someone tries to buy thousands of dollars’ worth of jewelry or electronics in a location far from home. Roskam says such a program could detect prescriptions that don’t match up with a prescribing doctor who has treated that patient, for example.

Roskam says fraud and waste in Medicare and Medicaid amounts to $60 billion annually – some of it with criminal intent, some of it just error – and this program could cut that in half.
The effort, which has bipartisan support in Congress, also has the backing of AARP. “It’s critical that Congress adopt responsible solutions that will save taxpayer dollars and improve the overall efficiency and cost-effectiveness of our nation’s health care system,” said Bob Gallo, Illinois state director of AARP.
Roskam has introduced a bill like this before, but has not yet found success.
(Copyright WBGZ Radio /

Texas man sentenced for Medicare scam

Associated Press
Posted on June 18, 2013 at 7:32 PM
HOUSTON (AP) — Federal prosecutors say a 48-year-old man has been sentenced to six years in prison for operating bogus ambulance companies that fraudulently collected $3.6 million in Medicare payments.
Julian Kimble was sentenced Tuesday after being convicted of conspiracy to commit health care fraud and other charges. He also must pay back the money he collected. Kimble pleaded guilty to the charges in November 2011.
Prosecutors say Kimble operated four ambulance companies in the Houston area from 2008 to 2010. He routinely billed the federal Medicare program for ambulance transports that were not provided, not needed or not ordered by a treating physician.
He and others transported Medicare beneficiaries in vans or sedans. Kimble received kickbacks from the owners of community mental health centers in exchange for supplying patients to their facilities.

Aetna to stop selling individual plans in Calif


Published: June 18, 2013
SACRAMENTO, Calif. (AP) — Aetna Inc. will stop selling individual health insurance policies in California next month, just weeks after opting out of the exchange that is being established as part of the national health care reforms, a state regulator said Tuesday.

California Insurance Commissioner Dave Jones said he was disappointed in Aetna's decision because consumers need more choices. The decision does not affect people who have Aetna insurance through their employer.

"This is not good news for California consumers," Jones said in a statement. "A competitive market with more choices for consumers is important, as we implement the Affordable Care Act and health insurance coverage is a requirement."

Aetna is a relatively small player in California's individual health insurance market. According to 2011 figures compiled by the California HealthCare Foundation, Aetna has about 5 percent of the state's individual health market. By comparison, Anthem Blue Cross, Blue Shield and Kaiser share 87 percent.

Aetna says it has about 58,000 individual enrollees in the state and expects to have about 49,000 by the end of the year. It plans to withdraw from the state at the end of the year but will continue to offer small and large group plans, as well as Medicare, dental and life insurance products.

Starting Oct. 1, those seeking to buy their own health insurance will be directed to Covered California, the state's new health insurance exchange. Aetna was not among 13 insurance carriers that will sell individual coverage to millions of Californians through the exchange.