Monday, July 29, 2013

Indictments returned in Georgia Medicaid fraud cases

From a press release issued by the Office of the Georgia Attorney General:

On July 25, 2013, a Cobb County Grand Jury issued an indictment against co-defendants Garry Hankerson, Lisa Hankerson, Pierre Hixon and Londrea Buchanan on charges of violating the Georgia Racketeer Influenced and Corrupt Organizations Act (RICO) (O.C.G.A. § 16-14-4(c)), Conspiracy to Defraud the State (O.C.G.A. § 16-10-21(a)) and Medicaid Fraud (O.C.G.A. § 49-4-146.1(b)).

The indictment alleges that Garry Hankerson and Lisa Hankerson, husband and wife, submitted false billing to the Georgia Medicaid program over the course of four years. Their company, First Step Counseling Services, Inc., was enrolled in a Medicaid program known as Intensive Family Intervention (IFI), which provides in-home mental health counseling to youths diagnosed with severe behavioral disorders. According to the indictment, First Step was paid over $650,000 by the Georgia Medicaid program between 2006 and 2010 while falsely billing counseling services. Mr. Hixon and Mr. Buchanan allegedly signed their names to patient progress notes purporting to have provided IFI services when in fact no services had been rendered, and patient chart documents to support billing for unrendered services were revealed to contain forged signatures.

Violation of the RICO Act carries a five to twenty year prison sentence, as well as a fine of up to three times the financial gain realized by those engaged in the racketeering activity. Medicaid Fraud is punishable by one to ten years in prison and a fine of $10,000. Conspiracy to Defraud the State is punishable by one to five years in prison.

The case is being prosecuted by Assistant Attorney General Lyndie Freeman, with assistance from Samuel M. Shapiro, a third-year law student at Georgia State University College of Law practicing under Georgia’s Third-Year Practice Act. Investigator Bradford Bartels and Investigative Auditor Amy Snow investigated the case with the assistance of Criminal Analyst Tish Murray, and the Georgia Department of Community Health.

An additional release has also been issued by the Attorney General's Office:

On Thursday, July 25, 2013, a Cobb County Grand Jury indicted Timothy Robinson on four counts of Medicaid Fraud (O.C.G.A. § 49-4-146.1 (b) (1)) and four counts of Identity Fraud (O.C.G.A. § 16-9-121) for falsely billing Georgia Medicaid for services that were not provided.

Robinson was the owner and operator of Robinson Rehabilitation Services, Inc., which offered speech therapy services. He employed four speech therapists to provide speech therapy services, mainly around the Metro Atlanta area. He was authorized to submit billing on their behalf to Georgia Medicaid during their employment with Robinson Rehabilitation.

An investigation revealed that the speech therapists terminated their employment, each at different times in 2009 and 2010. From roughly 2009 until February of 2013, Robinson submitted false claims for reimbursement to Georgia Medicaid using the four speech therapists’ provider identification and provider numbers after they had terminated employment with Robinson Rehabilitation. In total, Robinson fraudulently received $549,326.05 in Medicaid payments to which he was not entitled.

Medicaid Fraud is punishable by one to ten years in prison and a fine of $10,000. Identity fraud is punishable by one to ten years in prison and a fine of up to $100,000.

Assistant Attorney General Henry A. Hibbert is prosecuting the case on behalf of the State of Georgia. The case was investigated by Investigator Ralph Harper and Auditor Investigator Aaron Cohen of the Georgia Medicaid Fraud Control Unit.

Why NHS England is launching 'TripAdvisor' for patients

Unleashing the power of people is going to be fundamental to improving outcomes across health care, says Tim Kelsey, National Director for Patients and Information at NHS England.

Last weekend it emerged that 22 serious incidents are being investigated in connection with the line Photo: PA
When patients are ignored, they are most at risk: that was the central conclusion of the report by Robert Francis QC into Stafford hospital. It has been at the centre of every NHS scandal - the quality of care is jeopardised if the patient voice is not heard and respected.
I recently met a former nurse whose daughter has severe learning disabilities. She was exhausted by the powerlessness and routine indignity of her experience: often she would turn up at the A&E department and wait for hours to be admitted and then wait again for a hoist to arrive by the bedside so that her daughter could be lifted from her wheelchair onto the bed. 'I wish they would remember us,' she says. She complains but her voice has not been heard; her experience as a customer and patient has not improved.
It's not everyday, everywhere, for every patient - most, by far, receive an exceptional service, but to ensure the NHS delivers high quality care for all, we need transparency of the patient and carer experience. It is the absence of this transparency that often allows poor care to go undetected.
So on Tuesday we are publishing the first results of the Friends and Family test - the first time a health service has reported a single measure of patient satisfaction for every hospital. Patients and carers have been asked to score (on a six point scale) the quality of service on inpatient wards and A&E in English hospital trusts on this basis: ‘How likely are you to recommend our ward or A&E department to friends and family if they needed similar treatment?’. We have encouraged trusts to ask further questions to gather more specific service feedback. From now on, results will be published every month on the NHS Choices website ( so that citizens can hold local services accountable for improvement. In most cases, nurses and doctors get the feedback weekly so they are able to target improvements as quickly as possible.
This is the boldest move yet to promote real openness in the NHS and to concentrate our focus on improvement in care. For a year, a pilot has been running in the Midlands and East region of the NHS in which more than a third of a million people have given their feedback. Frontline staff have been quick to embrace this data as a tool to change things for the better. People complain about standards of cleanliness, isolation, lack of communication and poor food. NHS workers have been able to respond: switch the heating up, provide fruit on the ward, take more time to tell patients what is happening to them - or simply have a bit of a chat. Mid-Staffs would not have had such tragic consequences if action had been taken on patient complaints far sooner. This kind of routine feedback enables a different kind of conversation between the patient and clinician.
We hope that comments will be complimentary. In Chelsea and Westminster hospital A&E one left a comment along these lines 'I was drunk but the staff still treated me with respect' - a reminder of the situations extraordinary NHS staff deal with on a daily basis.
This kind of information - user-generated feedback is the jargon - is now fundamental to the way we make choices as consumers in the rest of our lives. Trip Adviser was launched 13 years ago and has more than 100m hotel customer reviews on its site; customer ratings and comments on retail sites like Amazon have transformed the way in which many people buy things. In New York, more than 90,000 citizens each day feedback on local services and this, according to Mayor Michael Bloomberg, has become one of the most powerful tools the city has to target improvements.
The NHS is not a hotel chain nor a city authority: but there are vital lessons it can learn about the power of transparency and feedback. Unleashing the power of people in this way is going to be fundamental to improving outcomes across health care - and to the effectiveness and sustainability of the NHS.
Transparency is not universally welcome in this public service - being open can be difficult and challenging - but the NHS is putting the patient voice irrevocably into the mainstream of its activities. By October, we will have extended the measure to all maternity services and by the Spring of 2015 to every service which treats NHS patients.
Today we will learn some home truths about the NHS: some Trusts will be surprised by the number of patients who would recommend their services and they will need to take a long hard look at how they quickly transform their customer experience. We will all be watching their progress. We need a transformation in the quality of customer service in health and care: patients must be respected as people. The NHS belongs to us all.

Hospital Networks Reject ObamaCare Initiative


Nine major hospital networks just decided they'd had enough of being "Pioneers" for ObamaCare.
They withdrew from the health reform law's Pioneer Accountable Care Organization (ACO) initiative, which launched in January 2012 with 32 health systems participating.
These ACOs are supposed to integrate doctors, hospitals and other providers into one seamless network that could "coordinate" care for Medicare patients — and in so doing, eliminate waste and control costs.
But as these nine casualties illustrate, ACOs are going to fail in that mission. Worse, they'll diminish the quality of care that Medicare patients receive.
Nationwide, about 425 private and public ACOs are in operation. These groups have agreed to a new government payment structure that essentially offers bonuses if they keep costs down while still meeting quality-of-care benchmarks.
If the provider groups save money, relative to the Medicare status quo, they can share in the savings with the government. But if they fail to keep costs down, in most cases, their risk of losing money is limited.
The 32 "Pioneer" ACOs can keep a greater share of any savings they generate — but also take on more downside risk. After two full years, successful Pioneers can leave the conventional structure, whereby providers bill Medicare for every procedure they perform, and instead take a flat fee per patient.
The exit of the nine provider groups "really shows a critical cost-containment approach in the Affordable Care Act is running into real problems," according to Harvard health policy professor Robert Blendon.
The Pioneer program was intended to emulate health care systems like the Cleveland Clinic in Ohio, the Mayo Clinic in Minnesota, Utah's Intermountain Health, and Pennsylvania's Geisinger Health System. All have been celebrated for streamlining administrative procedures, efficiently coordinating care among the health providers in their networks, and lowering costs.
But their success is largely the result of their unique business and medical cultures. None of them provides an easy template for creating a national network of ACOs.
Tellingly, these same organizations have refused to become ACOs. In a 2011 letter, the Cleveland Clinic explained its decision not to participate by citing "significant administrative burdens" and noting the law's regulatory red-tape had "little to do with outcomes." The Mayo Clinic and Geisinger made similar arguments.
Health systems have cooled to the ACO concept in part because the federal government is six months behind in providing them the Medicare claims data they need to comply with the rules.
Providers are also concerned about the risks they have to assume to participate. If they don't realize the "savings" that regulators demand, they'll have to just take the loss — regardless of how much time, effort, or expense it takes to treat someone.
The intent is to force ACOs to be more efficient. But this setup gives providers substantial incentives to skimp on medical care.
ACOs could also face new legal liabilities. Last month, the Journal of the American Medical Association (JAMA) published a paper by Harvard professors H. Benjamin Harvey and I. Glenn Cohen warning that patients could potentially sue entire ACOs for medical malpractice by claiming that their "actions or policies prioritized cost savings over patient safety."
Harvey and Cohen also raised the possibility of a "class action suit ... against institutional policies felt to be potentially harmful to patients, such as physician incentives payments" for keeping costs down.
If they're right, then any savings an ACO generates could be eaten up by legal settlements.
The two professors suggest that ACO doctors adhere to "evidence-based medicine" protocols, following the same treatment plan for every similarly situated patient, in order to immunize themselves against lawsuits.
But medical opinions vary widely depending on the patient and circumstances.
For instance, the medical community has debated when to give women mammograms for well over a decade now.
Further, what works well for one patient might not for another. Doctors need to be free to offer personalized treatment rather than worry about whether Medicare will pay for a procedure that isn't part of the standard protocol — or whether they'll be reprimanded for deviating from the norm.
For all this disruption, ACOs are forecast to deliver savings of just $4.9 billion through 2019. That's equivalent to less than 1% of Medicare spending.
Patients should hope that these nine hospital groups are harbingers of many more to reject ObamaCare's ACOs.
• Pipes is president, CEO and Taube Fellow in Health Care Studies at the Pacific Research Institute. Her latest book is "The Cure for ObamaCare" (Encounter 2013).

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Universal Health Services, Inc. Reports Financial Results For Three And... -- KING OF PRUSSIA, Pa., July 25, 2013 /PRNewswire/ --

Universal Health Services, Inc. Reports Financial Results For Three And... -- KING OF PRUSSIA, Pa., July 25, 2013 /PRNewswire/ --

Beth Israel Deaconess Medical Center to Pay $5.3 Million to Resolve Improper Medicare Claims

JULY 29, 2013
BOSTON – United States Attorney Carmen M. Ortiz and Susan J. Waddell, Special Agent in Charge of the Department of Health & Human Services, Office of Inspector General announced today that Beth Israel Deaconess Medical Center (BIDMC), a teaching hospital located in Boston, has agreed to pay the United States $5.315 million to settle allegations that it violated the False Claims Act by billing Medicare for inpatient admissions that should have been billed as lower reimbursed outpatient or observation services. The improper claims were submitted from June 1, 2004, through March 31, 2008.

The settlement resolves government allegations that BIDMC inappropriately submitted claims to Medicare for one-day stay inpatient admissions for patients with congestive heart failure, chest pain, and certain digestive and nutritional disorders. These claims should have been billed as observation services as the patients were briefly admitted for the limited purpose of observation and discharged the next day. In addition, the settlement resolves allegations that BIDMC submitted claims to Medicare for less-than-one day (zero day) stays that should have been billed as outpatient or observation services. Medicare reimburses hospitals, like BIDMC, at significantly higher amounts for inpatient admissions compared to outpatient or observation services. BIDMC has not admitted liability or wrongdoing in connection with the settlement.

“Today’s settlement furthers two critical purposes: ensuring that precious federal health care dollars are spent appropriately and in accordance with the law, and emphasizing that patient needs, not the bottom line, must be the basis for treatment decisions,” said U.S. Attorney Ortiz.

"When hospitals unnecessarily admit Medicare patients for short inpatient stays when the appropriate treatment would be outpatient or observation care, they improperly boost hospital profits at significant expense to taxpayers and patients," said HHS-OIG's Waddell. "We are committed to uprooting such schemes to eliminate waste in federal health care programs."

This settlement illustrates the government's continued emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. 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 this effort is the False Claims Act. Since 2009, the Justice Department has recovered a total of more than $14.8 billion through False Claims Act cases, with more than $10.8 billion of that amount recovered in cases involving fraud against federal health care programs.

This matter was investigated by Investigator Kristen Israelson of the Department of Health & Human Services, Office of Inspector General, Boston Regional Office of Investigations. It was handled by Assistant U.S. Attorney Jennifer Cardello and Special Assistant U.S. Attorney John O’Brien, both from Ortiz’s Affirmative Civil Enforcement Unit, and Senior Trial Counsel Marie Bonkowski of the Commercial Litigation Branch of the Justice Department's Civil Division. 

MORSTAD: Medicare: Improving lives for 48 years - The Lufkin News: Community

Posted: Monday, July 29, 2013 1:15 am
July 30 marks the 48th anniversary of Medicare, the national health insurance program for Americans 65 and older, signed into law by Texas’ own President Lyndon B. Johnson in 1965 as an amendment to the Social Security Act.
At the signing, President Johnson noted that, “every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.” Indeed, for nearly half a century, Medicare has lifted millions of older Americans out of poverty and has provided them with a safety net that they have rightly earned.

Today, Medicare provides affordable health coverage to roughly 52 million Americans, allowing them to lead more productive lives. Yet Medicare has reached a critical juncture. According to the Centers for Medicare and Medicaid Services, the Medicare trust fund will be exhausted in 2026. Politicians have used this statistic against millions of Americans who rely on Medicare. If we don’t cut benefits for today’s retirees, they say, benefits will cease to exist for future retirees.
Two years ago, AARP kicked off a national listening initiative, You’ve Earned a Say, to ensure the millions of Americans who pay into Medicare have a voice in the debate over its future. Millions of our members have sent a clear message to Washington: We should not balance the federal budget on the backs of our nation’s seniors.
Due to rising health care costs and changing demographics, Medicare faces real challenges, and we at AARP are tackling these challenges head on. We’ve said that we can reduce costs throughout the health care system, by clamping down on high drug prices, by improving care coordination and the use of technology and by cutting over-testing, waste and fraud. These commonsense solutions will ensure the longevity of Medicare so that seniors can continue to receive the affordable health care they deserve.
It’s important to note that the Affordable Care Act has already extended the life of Medicare by implementing key reforms that will save $500 billion over the next 10 years. From curtailing exorbitant payments to private insurers to cracking down on fraud and abuse, Washington has shown that it can accomplish real savings intelligently and responsibly, without cutting benefits for current or future retirees.
In order to reduce high prescription drug prices, we also must stop pharmaceutical companies from gaming the system. Right now, some brand name drug companies are driving up the cost of health care by entering into agreements with generic drug companies, paying them to delay bringing a competing product to the market. Moreover, Medicare should be allowed to negotiate with pharmaceutical companies for lower drug costs, which isn’t permissible under current law. Allowing Medicare to use the bargaining power of its 52 million beneficiaries to negotiate for lower prescription drug prices, particularly for high-priced brand name drugs, could save money for seniors and reduce the cost of health care.
Improving care coordination is essential to making sure patients receive safe, high-quality care. We can do this by creating systems that better connect doctors and health care facilities and take advantage of advanced information technology. More effective care coordination will also reduce medical errors and  help prevent dangerous, preventable hospital re-admissions while also ensuring patients are getting recommended care and saving taxpayer dollars.
It is estimated that Medicare could save hundreds of billions of dollars by reducing waste and stepping up fraud detection. For example, Medicare currently pays all health claims and then has to chase down providers if an error or fraud is detected — and too often the improper payment is never recovered. By improving technology, we can flag fraudulent claims before they are paid. We can also use technology to crack down on criminals who file false Medicare claims. By removing personalized information from Medicare identification cards, we can develop new cards that can track and confirm that Medicare is being billed for only those services a patient receives.
The proposals we are advocating for are not gimmicks but solutions that will improve and strengthen Medicare today and for future generations. Medicare has been successful for nearly half a century and is still a success today. If Washington takes the necessary steps, Medicare can be strengthened and improved for the next generation of seniors. By doing so, we can, in the words of President Johnson, “reaffirm the greatness of America.”
Tim Morstad helps lead outreach efforts for AARP in Texas.

MORSTAD: Medicare: Improving lives for 48 years - The Lufkin News: Community

Dartmouth-Hitchcock Aces ‘ACO’

Hospital Hits All Medicare Benchmarks, Gets $1 Million