Ambulance Company Owners Sentenced to Prison for Fraud Scheme

The two men have also been ordered to repay more than $3 million in restitution for their health care fraud scam that used falsified reports to bilk money out of the federal Medicare program.

The owners of a Feasterville-based ambulance company have been sentenced to federal prison after they pled guilty to 41 counts of health care fraud, wire fraud and related charges, according to a press release from the Department of Justice.

Aleksandr N. Zagorodony, 39, of Upper Southampton, was sentenced to 78 months in prison for a fraud scheme involving MedEx Ambulance Inc., located in Feasterville. Zagorodny was the president and a founder of MedEx Ambulance. 

MedEx Ambulance was ordered to be dissolved after it has been excluded from participation in Medicare and its assets are transferred to the government to satisfy restitution and forfeiture obligations. Each defendant had pleaded guilty to all counts in a 41-count indictment including health care fraud, false statements in connection with health care matters, wire fraud, and conspiracy to commit health care fraud and wire fraud.His 36 year-old brother, Sergey Zagorodny, from Philadelphia, the former vice-president and co-owner of the company, was sentenced to 60 months in prison for his involvement in the health care fraud scheme. 

Defendant MedEx Ambulance and its owners transported patients who were able to walk and could travel safely by means other than ambulance and who were not eligible for ambulance transportation under Medicare requirements. 

Falsified reports made it appear that the patients needed to be transported by ambulance when the defendants and their employees knew otherwise. The defendants billed for the ambulance services as if those services were medically necessary. The Medicare program was bilked out of more than $3.4 million through this fraud.

U.S. District Court Judge Berle M. Schiller also ordered restitution to Medicare in the amount of $3,418,358.81, a special assessment of $4,100 for each individual defendant and $16,400 for the corporation, and a three-year term of supervised release for the individuals and five years of probation for the corporation. 

The court ordered the forfeiture of four ambulances that had been purchased for more than $200,000, as well as forfeiture of bank accounts worth more than $40,000, and entered a money judgment against the defendants for $3,418,358.81. 

In connection with the sentencing, the company agreed to sell its base of operations and to provide the proceeds of that sale to the government in partial satisfaction of the defendants’ restitution obligations. The defendants and their wives also pledged to sell their family homes, as well as additional property, and to provide the proceeds of the sale of those assets to partially satisfy the defendants’ restitution obligations.

http://lowersouthampton.patch.com/groups/police-and-fire/p/ambulance-company-owners-sentenced-to-prison-for-health-care-fraud-scheme

Blue Cross Blue Shield of Texas Creates New Accountable Care Organization Alliance

Richardson-based Blue Cross and Blue Shield of Texas announced a new strategic alliance Thursday that it hopes will deliver improved, sustainable patient care while better managing healthcare costs, beginning in mid-2014.

The partnership—with Memorial Hermann Accountable Care Organization—is aiming to improve patients’ health while reducing costs through avoiding unnecessary hospital admissions, readmissions, emergency room visits, and duplication of services.

“This is a paradigm shift in paying for medical services,” Shara McClure, BCBSTX vice president for network management, said in a statement. ”The arrangement begins to move reimbursement away from fee for service to fee for value. In addition, the arrangement enables MHACO to harness clinical data to help drive medical care decision-making, enhance patient safety, and improve quality of care—all supporting the goals of better health and improved outcomes for BCBSTX members.”

The ACO model of healthcare delivery is designed to improve outcomes in three  categories: quality of care, patient experience and satisfaction, and cost efficiency. BlueCross will reach those goals by pursuing:

— Early identification of disease and illness through coordination of patient care

— Use of advanced technology and support services to make more informed decisions and facilitate transitions in care

— the implementation of an alternative or non-fee-for-service payment arrangement

— lower cost trends by increasing coordination among payers and providers

“Our relationship with Blue Cross Blue Shield of Texas around accountable care activities is consistent with Memorial Hermann’s commitment to quality outcomes and cost management,” said Chris Lloyd, CEO of MHACO. “The efforts we will undertake together will continue to advance the health of the populations we serve.”

BCBSTX is entering the ACO game just as another prominent North Texas healthcare organization is leaving it. Plus ACO—the accountable care organization comprised of Texas Health Resources and North Texas Specialty Physician— indicated to CMS in July that it intended to withdraw from the Pioneer ACO program, due to unmet financial goals.

“We look forward to working with CMS in other areas, and we will continue to support the accountable care framework’s fundamental components—reducing costs, improving patient outcomes through enhanced quality of care and care coordination across the continuum,” THR spokesman Wendell Watson said in an email to D Healthcare Daily in July.

Watson said Plus ACO was on track to save $10 million annually, yet was anticipating that it could be liable for a penalty between $6 million and $9 million at the end of the year. Watson said the group will continue to work with commercial plans to implement accountable care programs.

http://healthcare.dmagazine.com/2013/09/06/blue-cross-blue-shield-of-texas-creates-new-accountable-care-organization-alliance/