Tuesday, July 2, 2013

Fifty-Five Hospitals to Pay U.s. More Than $34 Million to Resolve False Claims Act Allegations Related to Kyphoplasty

Department of Justice
Office of Public Affairs
Tuesday, July 2, 2013

Fifty-five hospitals located throughout twenty-one states have agreed to pay the United States a total of more than $34 million to settle allegations that the health care facilities submitted false claims to Medicare for kyphoplasty procedures, the Justice Department announced today.  Kyphoplasty is a minimally-invasive procedure used to treat certain spinal fractures that often are due to osteoporosis.
In many cases, kyphoplasty can be performed safely and effectively as an outpatient procedure without any need for a more costly hospital admission.  The settlements announced today resolve allegations that the settling hospitals frequently billed Medicare for kyphoplasty procedures on a more costly inpatient basis, rather than an outpatient basis, in order to increase their Medicare billings. 
“Hospitals that participate in the Medicare program must bill for their services accurately and honestly,” said Stuart F. Delery, Acting Assistant Attorney General for the Civil Division of the Department of Justice.  “The Department of Justice is committed to ensuring that Medicare funds are expended appropriately, based on the medical needs of patients rather than the desire of medical providers to maximize profits.”

 The settling facilities, and the amounts they have agreed to pay, include the following:
• Atrium Medical Center, Middletown, OH, has agreed to pay $4,232,992.50.

• Altru Health System, Grand Forks, ND, has agreed to pay $1,492,690.

• Cedars Sinai Medical Center, Los Angeles, CA, has agreed to pay $1,485,846.

• Des Peres Hospital, St. Louis, MO, has agreed to pay $900,000.

• Mount Sinai Medical Center, Miami, FL, has agreed to pay $1,846,194.00.

• New England Baptist Hospital, Boston, MA, has agreed to pay $374,814.48.

• St. Anne’s Hospital, Fall River, MA, has agreed to pay $552,745.

• The Queen’s Medical Center, Honolulu, HI, has agreed to pay $1,055,249.57.

• Trover Health System, Madisonville, KY, has agreed to pay $1,162,837.

• Wayne Memorial Hospital, Goldsboro, NC, has agreed to pay $1,250,000. 

• Twenty-three hospitals affiliated with HCA Inc., Nashville, TN, have agreed to pay a total of $7,145,842.72.  These include:  Aventura Hospital & Medical Center (Aventura, FL); Capital Regional Medical Center (Tallahassee, FL); Coliseum Medical Center (Macon, GA); Coliseum Northside Hospital (Macon, GA); Conroe Regional Medical Center (Conroe, TX); Denton Regional Medical Center (Denton, TX); Doctors Hospital of Sarasota (Sarasota, FL); Edmond Regional Medical Center (Edmond, OK); Fawcett Memorial Hospital (Port Charlotte, FL); Fort Walton Beach Medical Center (Fort Walton Beach, FL); Garden Park Medical Center (Gulf Port, MS); JFK Medical Center (Atlantis, FL); Los Robles Regional Medical Center (Thousand Oaks, CA); North Florida Regional Medical Center (Gainesville, FL); Northlake Medical Center (Tucker, GA); Oklahoma University Medical Center (Oklahoma City, OK);  Palmyra Medical Center (Albany, GA); Redmond Regional Medical Center (Rome, GA); Southwest Florida Regional Medical Center (Fort Myers, FL); St. Lucie Medical Center (Port Saint Lucie, FL); Summit Medical Center (Hermitage, TN); Sunrise Hospital & Medical Center (Las Vegas, NV); and Wesley Medical Center (Wichita, KS).

• Six hospitals affiliated with Lifepoint Hospitals, Inc., Brentwood, TN, have agreed to pay a total of $2,522,502.69.  These include:  Andalusia Regional Hospital (Andalusia, AL); Jackson Purchase Medical Center (Mayfield, KY); Lake Cumberland Regional Hospital (Somerset, KY); Minden Medical Center (Minden, LA); Russellville Hospital (Russellville, AL); and Western Plains Medical Complex (Dodge City, KS).     

• Five hospitals affiliated with Trinity Health, Livonia, MI, have agreed to pay a total of $3,910,017.53.  These include:  Mercy Medical Center – Dubuque (Dubuque, IA); Mercy Medical Center - Sioux City (Sioux City, IA); St. Joseph Mercy Hospital (Pontiac, MI); Mercy Health Partners (Muskegon, MI); and Mount Carmel New Albany Surgical Hospital (New Albany, OH).  

• Four hospitals affiliated with Morton Plant Mease BayCare Health System, Clearwater, FL, have agreed to pay a total of $2,378,325.45.  These include:  Morton Plant Hospital (Clearwater, FL); Morton Plant North Bay Hospital (New Port Richey, FL); Mease Dunedin Hospital (Dunedin, FL); and Mease Countryside Hospital (Safety Harbor, FL).  

• Three hospitals affiliated with Baptist Memorial Health Care Corporation, Memphis, TN, have agreed to pay a total of $691,168.  These include:  Baptist Memorial Hospital-Golden Triangle (North Columbus, MS); Baptist Memorial Hospital-Collierville (Collierville, TN); and Baptist Memorial Hospital-Memphis (Memphis, TN).   

• Two hospitals affiliated with Covenant Health, Knoxville, TN, have agreed to pay a total of $1,845,641.74.  These include Parkwest Medical Center (Knoxville, TN) and Methodist Medical Center of Oak Ridge (Oak Ridge, TN).

• Two Hospitals affiliated with Bayhealth Medical Center, Newark, DE, have agreed to pay a total of $1,115,306.37.  These include Bayhealth Kent General Hospital (Dover, DE) and Bayhealth Milford Memorial Hospital (Milford, DE).  

 “This office will continue to ensure that sound medical decisions determine the ultimate treatment of a patient, not the financial interests of hospitals,” said U.S. Attorney William J. Hochul, Western District of New York. “We will not stand by and allow hospitals to inflate their profits based on unnecessary hospital admissions at the expense of the Medicare program or any other federal program. The settlements announced today will help maintain the integrity of this important program and all government-funded programs.”
 “Whenever hospitals knowingly overcharge Medicare, critically needed resources are wasted and health costs are driven up,” said Daniel R. Levinson, Inspector General for the U.S. Department of Health and Human Services. “When taxpayers’ dollars are threatened, OIG and its federal partners will take action.”
The Justice Department has now reached settlements with more than 100 hospitals totaling approximately $75 million to resolve allegations that they mischarged Medicare for kyphoplasty procedures.  In addition to today’s settlement, the government previously settled with Medtronic Spine LLC, the corporate successor to Kyphon Inc., for $75 million to settle allegations that the company defrauded Medicare by counseling hospital providers to perform kyphoplasty procedures as inpatient rather than outpatient procedures.      
 “It has never been more important to protect the Medicare Trust Fund, and this includes ensuring that Medicare is not burdened with the high costs of medically unnecessary admissions.  The Office of Inspector General will continue to ensure that the Medicare Program is protected from fraud, waste, and abuse,” said Tom O'Donnell, Special Agent in Charge of the Office of Investigations of the HHS-OIG New York Regional Office.  “The settlements related to kyphoplasty billing that have been reached with over 100 hospitals represent one of the largest and most successful multi-party health care investigations in the nation.”
 All but four of the settling facilities announced today were named as defendants in a qui tam, or whistleblower, lawsuit brought under the False Claims Act, which permits private citizens to bring lawsuits on behalf of the United States and receive a portion of the proceeds of any settlement or judgment awarded against a defendant.  The lawsuit was filed in federal district court in Buffalo, N.Y., by Craig Patrick and Charles Bates.  Mr. Patrick is a former reimbursement manager for Kyphon, and Mr. Bates was formerly a regional sales manager for Kyphon in Birmingham, Ala.  The whistleblowers will receive a total of approximately $5.5 million from the settlements announced today.
 This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $10.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $14.7 billion.
The settlements were the result of a coordinated effort among the U.S. Attorney’s Office for the Western District of New York, the Commercial Litigation Branch of the Justice Department’s Civil Division, and the Department of Health and Human Services’ Office of Inspector General and Office of Counsel to the Inspector General.
The claims resolved by these settlements are allegations only, and there has been no determination of liability.


Los Angeles-Area Doctor and Patient Recruiter Plead Guilty to Participating in a Power Wheelchair Scheme That Defrauded Medicare of Over $10.1 Million

Department of Justice
Office of Public Affairs
Monday, July 1, 2013

A Los Angeles-area doctor and a patient recruiter pleaded guilty today for their roles in a power wheelchair fraud scheme that defrauded Medicare of over $10.1 million.
The plea was announced by Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney AndrĂ© Birotte Jr. of the Central District of California; Glenn R. Ferry, Special Agent in Charge for the Los Angeles Region of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG); Steven Martinez, Assistant Director in Charge of the FBI’s Los Angeles Field Office; and Joseph Fendrick, Special Agent in Charge of the California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse.
Dr. Emmanuel Ayodele, 65, of Los Angeles, and Alejandro Maciel, 43, of Huntington Park, Calif., pleaded guilty before U.S. District Judge George Wu in the Central District of California to one count of health care fraud and one count of conspiracy to commit health care fraud, respectively.
Ayodele admitted that he defrauded Medicare by participating in a power wheelchair fraud scheme with the operators of fraudulent durable medical equipment (DME) supply companies.  According to court documents, DME suppliers provided Ayodele with patients recruited by street-level patient recruiters or “marketers,” who illegally solicited people with Medicare benefits for power wheelchairs and other DME that the people did not need.  In court documents, Maciel admitted that he was one of these marketers.
Maciel admitted that he approached people at their homes, swap meets, grocery stores and other locations, and made various misrepresentations to the people about his true identity and Medicare.  Maciel admitted that these misrepresentations allowed him to gain the trust of Medicare beneficiaries and convince them to provide him with their Medicare billing and personal information, which Maciel, Ayodele, and their co-conspirators used to defraud Medicare.  Maciel also admitted that, through his misrepresentations, he convinced people to travel with him to fraudulent medical clinics and DME supply companies owned and operated by his co-conspirators.  Ayodele admitted that he owned one of these fraudulent medical clinics, Beth Medical Clinic, which he operated in Los Angeles.
Ayodele admitted that, at Beth Medical, he wrote medically-unnecessary prescriptions for power wheelchairs and DME.  Ayodele admitted he knew that the DME supply companies used the medically-unnecessary prescriptions and documents that he wrote to submit claims to Medicare for medically-unnecessary power wheelchairs and DME.  For example, Ayodele admitted that the operators of fraudulent DME supply company Bonfee Inc., who were indicted with Ayodele and Maciel on Medicare fraud charges, paid Ayodele to write a medically-unnecessary power wheelchair prescription for one of Bonfee’s customers, and then used that prescription to submit a false power wheelchair claim to Medicare that totaled over $6,000.
Maciel admitted that his profit from the scheme came in the form of illegal kickbacks paid to him for every person whose Medicare billing and personal information his co-conspirators successfully used to bill Medicare for power wheelchairs or other items of DME.  According to court documents, once his co-conspirators successfully billed Medicare, Maciel delivered the power wheelchairs and other DME to the people whom he recruited.  During these deliveries, Maciel observed that the people could walk, and that they did not have a legitimate need for the wheelchairs and other DME.
As a result of their conduct, Ayodele and Maciel admitted that they and the owners and operators of Bonfee, Lutemi Medical Supplies, and other fraudulent DME companies submitted and caused to be submitted over $10,132,178 in false and fraudulent claims to Medicare.  Ayodele and Maciel admitted that Medicare paid Bonfee and the other DME supply companies over $5,388,754 on these false and fraudulent claims.
Two of Ayodele and Maciel’s co-defendants, Charles Agbu, a former pastor who owned Bonfee, and Dr. Juan Van Putten, have pleaded guilty to Medicare fraud charges and are scheduled for sentencing on Aug. 15, 2013, and Sept. 26, 2013, respectively.  Ayodele and Maciel’s other co-defendants, Obiageli Agbu and Candalaria Estrada, are scheduled for trial on July 9, 2013.
The owner of Lutemi, Olufunke Fadojutimi, a registered nurse, was arrested on May 14, 2013, on Medicare fraud charges.  Fadojutimi is scheduled for trial on Oct. 22, 2013. Defendants are presumed innocent unless proven guilty in court.
At sentencing, scheduled for Sept. 30, 2013, Ayodele and Maciel each face a maximum penalty of 10 years in prison and a $250,000 fine.
The case is being prosecuted by Trial Attorneys Jonathan T. Baum, Alexander Porter, William Kanellis and Blanca Quintero of the Criminal Division’s Fraud Section.  The case is being investigated by the FBI, HHS-OIG and the California Department of Justice.
The case 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 Central District of California.  The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.


$543 Million in Overpayments by Medicare, according to OIG


The Medicare system may never collect more than $543 million in overpayments made in 2010, a federal inspector general's report released Tuesday shows, because Medicare entered only a summary of each bill in its new system.
The new accounting system for the Center for Medicare Services (CMS) and systems used by Medicare contractors did not extract data automatically, the report said, so information about providers and contractors was lost. Medicare officials, the report said, determined it would require thousands of hours to re-enter data on health care providers into the new system.
The lack of accurate information also makes it difficult to determine where the errors were made, who might be defrauding the system and which providers have re-entered the system under a new name while still owing the government money, according to the report by the Department of Health and Human Services inspector general.
Overpayments occur when the government pays a provider too much after a billing error. There was a combined $9.6 billion in overpayments for Medicare Parts A and B in 2010.
The report found that Medicare provided detailed information on only seven of 39 delinquent contractors the inspector general asked for, or about $69 million of the unrecovered money. Some contractors told the inspector general that many providers aren't notified of overpayments if the government doesn't provide basic information, such as good mailing addresses for the providers.
Investigators found that Medicare should have used an automated system to extract the provider data to make it accessible for the new Medicare accounting system.
"Reducing the incidence of overpayments is a high priority for CMS," agency spokesman Brian Cook said. "Even as an overpayment is designated 'currently not collectible,' we continue to aggressively pursue repayment, including through our own internal processes, referral to the Department of Treasury and extended repayment schedules."
Medicare has improved its method of limiting overpayments before they are made, wrote Marilyn Tavenner, Medicare's administrator, in a letter to the inspector general.
Information about some Medicare providers has fallen through the cracks, the report said, because some providers have changed addresses and not given updated information to the government. In other cases, the inspector general recommended Medicare use tax identification numbers to collect overpayments from providers who have resumed business without paying previous bills.
CMS said it's the responsibility of the provider to enter correct address information in the new system. In the past, the government mailed checks to providers. However, providers receive payment through direct deposits into their banking accounts, which means they might not be as concerned about making sure their address is correct in the system as they had been in the past


Why 2013 could turn out to be a watershed year for telehealth

Providing health services remotely can reduce hospitalisations, save lives and help care for people in tough economic times
Remote care
Remote care can play an important role in helping to reduce the mounting pressure on the NHS. Photograph: Graham Turner for the Guardian
Telehealth has the potential to reduce hospitalisations and save lives. It also has an important role to play in caring for people against a challenging economic backdrop.
A report from the King's Fund (Transforming the Delivery of Health and Social Care) recently stated that the health and social care delivery system has failed to keep pace with the needs of an aging population, the changing burdens of disease and rising patient and public expectations.
It has been argued by government, hospital trailblazers and charitable organisations that remote care will play a key role in the hospital of the future. But I would argue that it's time to stop waiting for the future: remote care has an important role to play right now. The mounting pressure on our health system must be addressed imminently.
In fact I believe that a confluence of factors could make 2013 a watershed year in the move to transform and future-proof the NHS.

Joined up care delivery

The Health and Social Care Act 2012 is the most extensive reorganisation of the structure of the NHS in England to date. It is believed that clinical commissioning groups (CCGs) will be better placed than their predecessors (primary care trusts) to plan for patients' needs, in part because commissioning will be led by GPs rather than managers.
Telehealth is particularly well suited to providing quality care in this environment. It equips patients with the tools they need to learn how to self-care, and enables co-ordinated care to be delivered through a team of professionals, including the GP, community nurse, dietician and physiotherapist directly into the home.
The first report from the Whole System Demonstrator project showed how telehealth can improve efficiency and outcomes; as did the community matrons' experience of using telehealth to monitor patients with chronic obstructive pulmonary disease (COPD) at central Lancashire trust. For the patients who received the Intel-GE Care Innovations™ Guide, the trust recorded a 21% reduction in hospital readmissions and patients reported a reduction in anxiety levels.

Stimulating home care

But how do we move from sporadic trials to widespread deployment? In part, by recognising that the NHS, like any other employer, has a finite amount of money and needs to balance its books.
The new year of care tariff (YOC) will encourage healthcare providers to deliver whole care requirements for a year. Its introduction essentially encourages a new commissioning process, where the CCGs can contract with one or many organisations to ensure the health risks of a population are managed within a contained budget or tariff.
Adjusting payment based on outcome and prevention, rather than the number of hospital admissions for example, should serve as a cogent incentive for innovation in the form of telehealth.
The right incentives should encourage providers to seek out the best means of treating patients and monitoring conditions before they are allowed to deteriorate.
By taking an integrated approach, all patient needs, including their social and mental care requirements, will be better considered. This should lend itself to the spread of telehealth by encouraging new provider services to co-ordinate care delivery across primary and secondary care, in the community, while helping patients take a more active role in their own health – thereby fulfilling the YOC tariff's pledge to pave the way for a more complete patient experience.
The move to telehealth also has a greater chance of moving from theory to practice with the establishment of the academic health science networks (AHSNs) – a new tier of organisations committed to improving the identification, adoption and spread of innovation in the NHS.
The reasons why telehealth's potential is finally coming to the fore can be attributed to a number of factors. With an aging population beset with long-term illnesses the need to ease the burden on the NHS is being keenly felt. Fortunately the technology is now advanced and ready to deliver manifold benefits, including uninterrupted care in the home. Since the drivers for change have only recently formed, including new organisations in control of the purse strings, only time will tell whether this is the age of telehealth – but the conditions are certainly ripe and ready.
Claire Medd is clinical director at EMEA at Care Innovations, an Intel GE joint venture
This article is published by Guardian Professional.

ASC Quality Reporting Program Specifications Manual Version 3.0 Released

A new edition of the "Ambulatory Surgical Center Quality Reporting Program Specifications Manual" has been posted to QualityNet, the only CMS-approved website for healthcare quality data exchange.
The specifications manual includes measure information and specifications for Medicare's ASC Quality Reporting Program. Version 3.0 of the specifications manual adds the measure ASC-8: influenza vaccination coverage among healthcare personnel.