Sunday, July 14, 2013

North Carolina: Provider auditing firm ‘unreliable’

Posted: Saturday, July 13, 2013 5:00 pm | Updated: 12:58 am, Sun Jul 14, 2013.
The Boston-based company that found $36 million in Medicaid overpayments to 15 New Mexico behavioral health providers — and claimed evidence of fraud by the companies — did a similar study with similar results in North Carolina.
However, the North Carolina state auditor last year found some of the findings against those providers were overstated, and the figures reported by Public Consulting Group were “not proven to be reliable.”
One North Carolina provider that allegedly overcharged the state by more than $1.3 million actually had overcharged by less than 2 percent of that amount, the North Carolina state auditor said.
No spokesman for Public Consulting Group could be reached for comment Friday. But a spokesman for the New Mexico Human Services Department on Friday defended the company’s work in North Carolina.
In New Mexico last month, based on the audit performed by Public Consulting Group, the state Human Services Department froze funding for 15 behavioral health providers and referred the audit to the Attorney General’s Office for possible criminal prosecution.
Three of the 15 providers have had their funding fully or partly restored. But eight of the providers filed a federal lawsuit against Human Services Secretary Sidonie Squier. In the suit, the providers claim the action has been financially devastating. Some of the behavioral health companies have begun furloughing employees and shutting down services.
New Mexico’s Human Services Department is in the process of contracting with five Arizona companies — at a cost of up to $17.8 million — to be “on stand-by” to provide help with behavioral health services.
In addition, the providers’ lawsuit claims Squier’s public statements saying there is evidence of fraud has damaged the reputations of the providers. They have demanded “a meaningful name-clearing hearing, as required by the due process clause of the Constitution.”
State Auditor Hector Balderas said Friday that his office has received complaints about the behavior health provider issue and that his auditors and investigators are currently making “formal inquiries” to decide what course of action to take. Balderas said he’s already reached out to the North Carolina state auditor concerning the PCG Medicaid audit in that state.
The providers’ lawsuit brings up Public Consulting Group’s work in North Carolina, saying the company made auditing errors in New Mexico similar to mistakes made in North Carolina.
The company was hired by that state’s Health and Human Services Department to help identify Medicaid fraud. The contract was based on how much potential overpayments to providers they could identify. PCG reported $38.5 million in Medicaid overpayments and was paid $3.2 million.
However, in a July 2012 report, North Carolina State Auditor Beth Wood found that of the $38.5 million overpayments cited, the Health and Human Services Department had only been able to collect $3.7 million — less than 10 percent.
Wood’s report said “recoupments identified by PCG have not proven to be reliable, so the actual benefit derived from the contract is unclear.”
The report found at least one example in which the initial overpayment claimed by PCB turned out to be drastically less.
According to Wood’s report, her office began receiving a number of complaints about PCG’s review process. They decided to re-review one of the companies, which PCG said had overpayments totaling $1.34 million. “As a result of the providers submitting additional documentation and re-reviews … the recoupment amount was revised downward to only $22,093. It was unclear whether this was the result of the additional documentation provided or PCG’s policy interpretations during the review process.”
Similar to the situation in New Mexico, Wood told WRAL TV in Raleigh, N.C., last year, “We’ve had some complaints from providers that they’re about to be put out of business because of all the time they’ve had to spend to prove that they really haven’t committed fraud.”
Wood told the station that the way the contract was written was an incentive to PCG to inflate its findings.
Matt Kennicott, external affairs director for New Mexico’s Human Services Department, said the company’s New Mexico contract was not based on how much potential overpayments it identified. “There is zero financial incentive for them to produce findings,” he said.
A spokeswoman for the North Carolina Department of Health and Human Services told WRAL last year, “The auditor’s report does not emphasize one crucial piece of information — the value of identifying fraudulent providers and stopping them from ever operating again. Even if we don’t recoup all the money lost, it’s impossible to put a price tag on the deterrent effect of our efforts. We may never know just how many millions we will prevent from ever going out the door.”
Kennicott said North Carolina benefited from PCG’s work there and has seen a 23 percent improvement in provider compliance in the past two years because of the audits.
“The vast majority of PCG’s clinical findings have been upheld by the [North Carolina] Department of Health and Human Services during their due process hearings,” Kennicott said. “More than 85 percent of their audit findings have been upheld during hearings upon appeal” in North Carolina, he said.
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North Carolina: Provider auditing firm ‘unreliable’ - The Santa Fe New Mexican: Local News

Harvard Medical School Focuses on Challenge of Healthcare Innovation

Boston: The Forum on Healthcare Innovation, a collaborative effort sponsored by Harvard Medical School and Harvard Business School, has released a report highlighting the results of the first of a series of annual conferences and surveys.

Titled “5 Imperatives: Addressing Healthcare’s Innovation Challenge,” the conference report represents the views of more than 100 experts from a wide variety of areas, including academics, physicians, healthcare providers, executives, public policymakers, investors, and insurers. The report summarizes the participants’ collective insights regarding one overarching concern: How can healthcare and business leaders best encourage innovations that lead to value—that is, the most optimal outcomes relative to dollars spent?

The accompanying survey reported several startling conclusions: Twenty percent of the more than 200 senior leaders responding to the full survey strongly believed that healthcare quality in the United States was starting from only a fair or poor position and falling behind other countries.

In addition, only one percent of them held the strongly positive sentiment that this country could significantly increase value through the combination of quality pulling ahead of other industrialized nations and healthcare costs growing more slowly than general inflation.

The Forum report prescribes five key imperatives most likely to yield practical progress:

Making value the central objective: In isolation, efforts to either reduce costs or improve outcomes are insufficient; we need to do both through care coordination and shared information.
Promoting novel approaches to process improvement: In the race for new products and services, we are overlooking important opportunities for improving the ways in which we deliver care. In addition, failure, managed wisely, represents an important component of experimentation and learning.
Making consumerism really work: Consumerism remains a strong idea with weak execution. We will achieve greater success when providers organize efforts around patient needs, and when patients become more active and informed agents in managing their own health.
Decentralization: We should facilitate the movement of care delivery and healthcare innovation from centralized centers of expertise to the periphery, where more providers, innovators, and patients can engage in collaborative improvement efforts.
Integrating the Old and New: Existing healthcare institutions must be reinforced with efforts to integrate new knowledge into established organizations and the communities they serve.
According to Harvard Business School professor Robert S. Huckman, co-chair of the Forum on Healthcare Innovation, “The 5 Imperatives report is a provocative compilation of core issues that can help us focus our energy, regardless of discipline, on the most truly urgent areas of innovation.”

Added co-chair and Harvard Medical School professor Barbara J. McNeil, MD, “The report reflects in microcosm the larger possibilities of the Forum itself: the collaborative power of healthcare and business leadership to provide care in which we can have confidence, at costs we can manage.”

Harvard Medical School Focuses on Challenge of Healthcare Innovation

Lawsuit alleges Jackson cardiologist falsified patient records to justify billing Medicare for unnecessary medical procedures

JACKSON, MI – Jackson cardiologist Dr. Jashu Patel falsely interpreted stress tests for patients as abnormal to justify billing Medicare for unnecessary cardiac procedures, according to allegations in a lawsuit settled this week.
Almost 90 percent of patients who were listed as having "abnormal" stress test results at Patel's practice, Jackson Cardiology Associates, between Jan. 29 and Feb. 28, 2007 had no significant coronary artery disease, according to the complaint filed by Ann Arbor cardiologist Dr. Julie Kovach with the U.S. District Court.
Kovach, previously employed as an independent contractor cardiologist at the practice, 205 Page Ave., also alleges that an elderly woman died as result of a cardiac procedure that was not needed and requested by Patel's office.
Patel, Jackson Cardiology Associates and Allegiance Health settled in a $4 million lawsuit that alleges that all three parties fraudulently and recklessly performed unnecessary cardiac procedures and billed them to federal health care programs.
Allegiance Health, Patel and Jackson Cardiology Associates all disagree with the allegations in the lawsuit and said they decided to settle in order to devote their resources to the care of their patients.
Kovach also alleged Allegiance Health officials received multiple complaints and warnings that Patel was performing these unnecessary procedures and continued to allow him to do so. Read the entire complaint by Kovach
Kovach is expected to receive $764,700 as part of the settlement.
"Unnecessary cardiac procedures and tests put patients at potential risk for life threatening complications, long-term effects of radiation exposure, and additional unnecessary and risky procedures as a result of the first one," Kovach said in a statement issued by Birmingham-based law firm Vezina Law. "Paying health care providers who perform unnecessary cardiac testing and procedures increases the cost of health care to all Americans."
Efforts to reach Kovach for additional comment were unsuccessful.
Health care fraud is a problematic issue across the country, with cases leading to settlements costing upward of hundreds of millions of dollars, said Louis Saccoccio, CEO of the Washington, D.C.-based National Health Care Anti-Fraud Association, a private-public organization comprised of private health insurers and federal and state government officials.
What is unique about the lawsuit involving Allegiance Health and Jackson Cardiology Associates is that it involved allegations of billing for unnecessary medical procedures, Saccoccio said. More commonly, health care fraud cases involve billing for procedures that were not performed in the first place, he said.
"That's a real extreme thing, as it relates to those patients," Saccoccio said about the allegations in the lawsuit against Allegiance Health and Jackson Cardiology Associates. "It has the potential to harm patients physically."
Kovach listed several patient cases between January and May 2008 and stated that they represented only a small sample of fraudulent activities by Patel and Jackson Cardiology Associates between 1998 and 2008. The following are some of the allegations filed in Kovach's complaint:
  • Patel has ordered unnecessary stress tests for patients and falsified patient records to make it appear that they needed the tests.
  • Patel has repeatedly ordered, performed, and billed for cardiac catheterizations for patients who did not meet any Medicare covered indications or medical guidelines.
  • In many cases, Patel falsified and manufactured complaints of symptoms in patients' charts.
patel.JPGDr. Jashu Patel
Allegiance settled the case for $1.8 million. Patel and Jackson Cardiology Associates settled for $2.2 million, according to the U.S. Attorney's Office.
Because the unnecessary procedures were paid for by the Medicare or Medicaid, the United States is entitled to monetary damages under the federal False Claims Act, which allows private citizens to sue those committing fraud against government programs, according to a statement from the U.S. Attorney's office.
Patel said his practice has provided care to patients in the Jackson community for more than 20 years and that the patients are the best judges of the practice.
"I'm really deeply saddened by what has occurred," Patel said about the allegations. "I want to put my resources back into the patients' care. Our patients are very supportive."
Patel has an active medical license that expires Jan. 31, 2014, according to the Michigan Department of Licensing and Regulatory Affairs. There are no complaints or disciplinary actions filed against Patel at this time, according to the office.
"It is very important to me to have excellent care in this town," Patel said. "We are trying to provide the best care for our patients."
Allegiance Health spokesman Jeff Kapuscinski said the hospital has brought in experts to review its processes and procedures to make sure they are based on evidence and best practices.
Kapuscinski said he believes there are some people who have concerns but has been pleasantly surprised by the support that the hospital has received.
"We place a great value in the trust that our patients have in our facility," he said. "Our main goal is to retain that trust that people have in us and in the care we provide."
In addition to the monetary settlement, the resolution also provides that Jackson Cardiology Associates and Allegiance Health will enter into integrity agreements with the U.S. Department of Health and Human Services Office of Inspector General.
The Office of Inspector General negotiates these agreements with health care providers and other organizations as part of the settlement, according to the department's website.
Providers agree to the obligations, and in exchange, the office agrees to not seek their exclusion from participating in Medicare, Medicaid or other federal health care programs.
An integrity agreement typically lasts five years and includes the following requirements:
  • Hire a compliance officer and appoint a compliance committee
  • Develop written standards and policies
  • Implement an employee training program
  • Retain an independent review organization to conduct annual reviews
  • Establish a confidential disclosure program
  • Report over-payments, ongoing investigations and legal proceedings
  • Provide an implementation report and annual reports to the Office of Inspector General on the status of the institution's compliance activities.
Although health institutions are required to have a compliance program, it is a significant event for a hospital or medical practice to be under an integrity agreement, Saccoccio said.
"(Health care providers) have to show they are complying with all (governmental) regulations that are in place," Saccoccio said. "It's a pretty stringent thing that they have to comply with to ensure that this doesn't happen again."