Research and Markets: Guide to the Patient-Centered Medical Home: Metrics, Models and Engagement

Published: Monday, Jun. 10, 2013 / Updated: Monday, Jun. 10, 2013 11:21 AM

DUBLIN -- 

Research and Markets (http://www.researchandmarkets.com/research/6dndl6/guide_to_the) has announced the addition of the "Guide to the Patient-Centered Medical Home: Metrics, Models and Engagement" report to their offering.
The patient-centered medical home (PCMH) has become a hallmark of healthcare delivery. Its team-based model is a mainstay of care coordination for thousands of physician practices that have already transformed themselves into medical homes - many of which are poised to step into an accountable care organization (ACO), according to 2012 market data.
In a nod to the PCMH's potential for improving care and controlling cost, many payors have placed case managers in medical homes to assist with stratification and care coordination of high-risk patients.

Guide to the Patient-Centered Medical Home: Metrics, Models and Engagement provides an overview of PCMH adoption and results and examines nuances of the model that have emerged in recent years - including the embedding of case managers on medical home teams.
Besides a complete set of benchmarks from almost 100 organizations on medical home adoption and program components, HIN's sixth annual PCMH analysis, this 155-page guide offers snapshots of thriving medical home programs, including the following:
- The statewide rollout of Florida Blue's medical home program, from practice selection to reimbursement models;
- The comprehensive PCMH consumer engagement and education effort underway at Horizon Blue Cross Blue Shield of New Jersey to position the Blues plan for accountable care;
- Advice on achieving Level III NCQA medical home recognition, joining an ACO, and participating in the CMS Comprehensive Primary Care initiative from Hunterdon Healthcare;
- Roadmap to the embedding of case managers: Geisinger Health Plan's selection, training, skill set, processes and benefits of case managers embedded within the payor's medical home practices, a model that has become an industry template for co-located case management.
Key Topics Covered:
Chapter 1: 2012 Benchmarks in the Patient-Centered Medical Home
Chapter 2: New Models in the Patient-Centered Medical Home
Chapter 3: The Medical Home Case Manager
For more information visit http://www.researchandmarkets.com/research/6dndl6/guide_to_the

12 CA Residents Accused of Attempting to Bilk Medicare of $22 Million Arrested as Part of Nationwide Crackdown

 

Los Angeles, CA (WorkersCompensation.com) - Twelve Los Angeles-area residents—including California’s second-largest biller for chiropractic services, a physician’s assistant, and owners of durable medical equipment (DME) and ambulance companies—were taken into custody today in relation to seven criminal cases that allege they cumulatively submitted more than $22 million in false billings to Medicare.
The charges filed in Los Angeles are part of a nationwide “takedown” by Medicare Fraud Strike Force operations in eight cities that led to charges against 89 individuals for their alleged participation in schemes to collectively submit about $223 million in fraudulent claims to Medicare.
The dozen defendants taken into custody are among 13 people charged in Los Angeles in cases that allege health care fraud. The 12 either were arrested this morning or self-surrendered to authorities after learning that they had been charged in federal court. All those defendants are scheduled to be arraigned this afternoon. A 13th defendant is a fugitive.
Dr. Houshang Pavehzadeh, of the Sylmar Physician Medical Group, allegedly billed Medicare more than $1.7 million for chiropractic treatments he never performed. During the scheme, which ran from 2005 through 2012, Dr. Pavehzadeh, 40, of Agoura Hills, became the second-largest Medicare biller in California for chiropractic services—even though he was not in the United States when some of the alleged services were performed. In addition to being charged with health care fraud, Pavehzadeh is charged with aggravated identity theft related to Medicare beneficiaries whose information he used to bill Medicare as a part of the scheme. When investigators tried to conduct an audit of Pavehzadeh’s claims, he falsely reported to the Los Angeles Police Department that he had been carjacked and that patient files requested by the auditors had been stolen from his car. Pavehzadeh surrendered this morning, and he is scheduled to be arraigned with other Los Angeles-area defendants this afternoon in the Roybal Federal Building.
Nine defendants affiliated with DME companies were also charged in five separate indictments.
Olufunke Fadojutimi, 41, of Carson, a registered nurse; Ayodeji Temitayo Fatunmbi, 41, formerly of Carson and now believed to be residing in Nigeria; and Maritza Velazquez, 40, of Las Vegas, were charged with health care fraud. The scheme allegedly revolved around Lutemi Medical Supplies, a DME company Fadojutimi owned and where Fatunmbi and Velazquez worked. According to the indictment in this case, Lutemi billed Medicare more than $8.3 million in claims, primarily for medically unnecessary power wheelchairs. Fadojutimi and Fatunmbi allegedly laundered Medicare funds in order to purchase fraudulent prescriptions for those power wheelchairs and pay illegal kickbacks to recruit Medicare beneficiaries. Fadojutimi was arrested this morning in Los Angeles, while Velazquez was arrested in Las Vegas. Fatunmbi is currently a fugitive being sought by federal authorities.
Susanna Artsruni, 45, of North Hollywood, and Erasmus Kotey, 76, of Montebello, a licensed physician’s assistant, allegedly worked together to commit health care fraud out of a medical clinic on Vermont Avenue where they both worked. Kotey allegedly prescribed medically unnecessary DME, including power wheelchairs, for Medicare beneficiaries. Many of those power wheelchair prescriptions were then used by Artsruni’s DME company, Midvalley Medical Supply, to support fraudulent claims to Medicare. In only four months, the clinic and Midvalley billed Medicare more than $525,000 for these fraudulent claims. Artsruni has previously been convicted of health care fraud and was on pre-trial supervision at the time she allegedly laundered some of the proceeds of this fraud. Artsruni was arrested this morning, while Kotey self-surrendered.
Three other DME cases were also charged, alleging fraudulent Medicare billing for medically unnecessary power wheelchairs that were sometimes never even delivered. In one case, Akinola Afolabi, 53, of Long Beach, the owner of Emmanuel Medical Supply, allegedly submitted more than $2.6 million in false and fraudulent billing to Medicare. In another case, Queen Anieze-Smith, 52, of Encino, and Abdul King-Garba, 47, of Westwood, the owners and operators of ITC Medical Supply, allegedly submitted more than $1.8 million in false and fraudulent billing to Medicare. In the third case, Clement Etim Aghedo, 53, of Fontana, the owner of Ace Medical Supply Company, allegedly submitted more than $1.8 in false and fraudulent claims to Medicare. Afolabi, Anieze-Smith, and King-Garba were all arrested this morning, while Aghedo self-surrendered.
In the seventh case brought as part of today’s takedown, three defendants affiliated with Gardena-based ProMed Medical Transportation, an ambulance company, were charged with submitting more than $5.9 million in false claims to Medicare between 2008 and 2011. ProMed’s owner, Yaroslav Proshak, 45, of Valley Village; general manager Sharetta Wallace, 35, of Inglewood; and office manager and biller Sergey Mumjian, 40, of West Hollywood, submitted claims for medically unnecessary transportation services and then created fake documentation purporting to support those claims. Proshak, Wallace, and Mumjian were arrested this morning.
The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and the Department of Health and Human Services to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.
The Los Angeles cases announced today are being investigated by a Medicare Fraud Strike Force team, which is composed of agents and investigators with the Federal Bureau of Investigation; the Department of Health and Human Services, Office of Inspector General; IRS-Criminal Investigation; and Medicaid Fraud Control Units, including the California Department of Justice. The cases are being prosecuted by attorneys from the United States Attorney’s Office and the Fraud Section of the Justice Department’s Criminal Division.
An indictment contains allegations that a defendant has committed a crime. Every defendant is presumed innocent until and unless proven guilty.
The charge of health care fraud carries a statutory maximum penalty of 10 years in federal prison. Money laundering carries a potential penalty of 20 years in prison. Aggravated identity theft carries a mandatory two-year prison term.

By WorkersCompensation.com 7 hours 11 minutes ago

WellCare executives convicted in fraud trial

        

Last Modified: Tuesday, June 11, 2013 at 4:46 p.m.

TAMPA, Fla. - Four former WellCare executives have been convicted of some, but not all, charges following a Medicaid fraud trial in Florida.

WellCare CEO Todd Farha, WellCare CFO Paul Behrens, Harmony Behavioral Health vice president William Kale and vice president of operations Peter Clay all faced multiple counts of medical fraud, conspiracy and making false statements. But after several weeks of deliberations, jurors in Tampa told U.S. District Judge James Moody on Monday that they were unable to reach verdicts for the more serious charge of conspiracy to commit medical fraud on each defendant.
Farha was found guilty of two counts of health care fraud, and acquitted of six other charges including giving false statements. Behrens also was found guilty of two counts of health care fraud and two counts of making false statements, but was acquitted of other two other false statement charges. Kale was found guilty of two counts of health care fraud and Clay was found guilty of two counts of making false statements.
Prosecutors say they haven't decided whether to retry to deadlocked conspiracy counts.
A sentencing date hasn't been set. On each of the health care fraud counts, Farha, Behrens and Kale face up to 10 years in prison. The other charges carry a maximum of five years.
Prosecutors say the four men defrauded the government out of more than $30 million. Dealing exclusively with Medicare and Medicaid claims, authorities say the executives produced false documents and formed Harmony Behavioral as a "shell company" to inflate the costs for behavioral health-care services.
Defense attorneys say the expenses were legitimate. They say the state knew about the arrangement but failed to give WellCare and other companies any guidance. They accused federal prosecutors turning a contractual dispute into a federal crime.

http://www.news-journalonline.com/article/20130611/APN/1306110925

Government may have leaked billion dollar Medicare decision

3:24 PM 06/10/2013

http://dailycaller.com/2013/06/10/government-may-have-leaked-billion-dollar-medicare-decision/

At least 436 employees of the Department of Health and Human Services received advance word of an upcoming Medicare decision, and now federal investigators are looking into whether they tipped off Wall Street investors.

A review of emails by Republican Sen. Charles E. Grassley of Iowa found that hundreds of HHS employees received advanced word of a billion-dollar Medicare decision weeks before the official announcement, according to the Washington Post. Trading in Humana and other private health insurers’ stock spiked in the period before the announcement.

Insiders at HHS had advance word of the Centers for Medicare and Medicaid Services’ April 1 decision to spend an additional $8 billion of the taxpayers’ money on the private-sector Medicare Advantage program. HHS officials told the post this was necessary due to the complexity of Medicare policy. Grassley wants to know how Wall Street investors learned of the federal ruling.

The Justice Department and the Securities and Exchange Commission have launched investigations to find out whether Wall Street investors gained prior access to knowledge of the decision.

Former director of the Medicaid program Thomas Scully claims it is likely that hundreds of people had access to the billion-dollar verdict, as it was a highly complex decision.

Grasseley told Post his office found 436 DHS employees knew of the decision nearly two weeks before it became public.

“This should sound an alarm,” Grassley told the newspaper. “It should result in better controls to avoid unfair access to information that the average investor could never tap.”

Read more: http://dailycaller.com/2013/06/10/government-may-have-leaked-billion-dollar-medicare-decision/#ixzz2VsKXjShX

Health Care Innovation

LETTER

Published: May 30, 2013

In his May 26 column, “Obamacare’s Other Surprise,” Thomas L. Friedman discusses how data that support medical decision-making and collaboration, dovetailing with new tools in the Affordable Care Act, are spurring the innovation necessary to deliver improved health care for more people at affordable prices.

This is just another example of how public policy is driving a smarter health care system focused on the quality of care, not the quantity of care delivered. That means increasing transparency and accountability, avoiding costly mistakes and readmissions, keeping patients healthy, and enabling new payment and care delivery models, like accountable care organizations, to work.

Last week, we reached an important milestone in the adoption of health information technology, which is a critical underpinning to this larger strategy.

More than half of all doctors and other eligible providers and nearly 80 percent of hospitals are using electronic health records to improve patient care — an increase of at least 200 percent since 2008.

There is much work yet to be done to change the habits of health care, and to continue the push toward secure information sharing, but by using policy to leverage market-based innovation, we are playing to America’s greatest strength to solve our most pressing problems.

FARZAD MOSTASHARI
Washington, May 28, 2013

The writer is national coordinator for health information technology for the Health and Human Services Department.

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Manipal Hospital ordered to pay 5 lakh for negligence | The Hindu

Manipal Hospital ordered to pay 5 lakh for negligence | The Hindu

Eleven years ago, a toddler admitted with cough and cold developed a gangrenous arm which had to be amputated

The Manipal Hospital in Bangalore and its four doctors have been directed by the apex consumer forum to pay Rs. 5.1 lakh towards rehabilitation of a child whose gangrenous right forearm was amputated due to their negligence.

The National Consumer Disputes Redressal Commission (NCDRC) observed that due to the medical negligence of the hospital and its doctors — paediatrician Meera Ramakrishnan, vascular surgeon Vasudeva Rao, consultant paediatric Arvind Shenoy and paediatric surgeon Jayanth Iyengar — “the child has to spend the entire life without her right forearm”. “Doctors have not been able to explain how the gangrene occurred. Therefore … medical negligence is clearly established.”

A bench presided by Justice Ashok Bhan directed the hospital and doctors to jointly pay Rs. 5 lakh to the parents “for the rehabilitation of baby Sandria by providing artificial limb and proper education and care” and also ordered Manipal Hospital to pay Rs. 10,000 as cost.

The order came on the appeals filed by the parents, Alfred and Rani Benedict, and the hospital and doctors, both sides challenging the order of the State commission which had directed the hospital and doctors to pay Rs. 5.1 lakh as compensation.

The parents, in their complaint before the Karnataka State Consumer Disputes Redressal Commission had submitted that in August 2002 they had taken their then two-year-old daughter, who was suffering from cold and cough, to Dr. Shenoy who had advised them to admit the child in Manipal Hospital, Bangalore.

Thereafter, she was diagnosed as suffering from pneumonia and was given intravenous fluids through a needle in her right arm. The parents alleged the needle blocked the blood supply, turning the forearm gangrenous, resulting in amputation.

While the parents had sought enhancement of compensation from the NCDRC, the opposite party contended they had not been negligent and the unfortunate complication occurred as the patient, who had pneumonia, had gone into septic shock.

The NCDRC rejected the hospital’s contention, saying “it appears they (doctors) have not followed the standards of medical practice”.

Redefining the language of health care

THE PODIUM

By Wayne Lowell

JUNE 10, 2013

Providing health care to the poor increasingly means providing health care to non-English speakers, and that’s a challenge that is about to get more challenging.

According to the US Census, more than 55 million people speak a language other than English at home. In Massachusetts, the number is 1.2 million. In the City of Boston, one in three residents speak another language.

At Cambridge-based Senior Whole Health, which provides health care to people who quality for both MassHealth and Medicaid and is known as a Senior Care Options plan, two out of three of our members do not speak English. The number of languages spoken by our membership is more than 30.

Navigating our complicated health care system is a challenge for anyone. For a non-English speaking person, the task is overwhelming – and can be deadly.

Non-fluency in English is associated with lower use of preventive services, higher utilization of expensive emergency room care, less ability to self-manage chronic diseases – and higher mortality, according to the Journal of the American Medical Association. In fact, according to JAMA, reading fluency is a more powerful variable than education for examining the association between socioeconomic status and health.

Navigating the system will get even more complicated next year when individuals and small businesses will be required to purchase health insurance under federal health reform. That will require them to compare and contrast various private health insurance policies through exchanges set up by the new law.

Meanwhle, immigration reform could add another seven million people, many of them not fluent in English, to Obamacare.

But there is a path to success. We have already helped over 10,000 people successfully navigate the health care system. Our model provides all-inclusive care directed by a case manager who provides one-stop shopping for the patient and his or her family in their native language. We emphasize preventive care and provide non-medical services, such as bilingual exercise classes, that support a healthy lifestyle.

Not only is this model keeping people healthier, but it’s saving taxpayer dollars by keeping poor seniors out of nursing homes longer and reducing hospital admissions by 25 percent, according to a study conducted for MassHealth.

Providing health care to the poor will require a new mindset about how to deliver — and define — health care.

Wayne Lowell is president and CEO of Senior Whole Health.

Medicare Advantage 2013 Spotlight: Enrollment Market Update

This data spotlight provides an overview of Medicare Advantage enrollment patterns in March 2013 and examines variations by plan type, state, and firm. It also analyzes trends in premiums paid by beneficiaries enrolled in Medicare Advantage plans, including variations by plan type, and describes the out-of-pocket limits and prescription drug coverage in the Part D “donut hole” provided by the plans in 2013.

This analysis finds that 14.4 million Medicare beneficiaries are enrolled in private Medicare Advantage plans in 2013, up nearly 10 percent from 2012. Since 2010, enrollment in Medicare Advantage plans has grown by 30 percent in spite of concerns that the payment changes enacted in the 2010 Affordable Care Act would lead to significant reductions in enrollment. While about 28 percent of Medicare beneficiaries nationally are now enrolled in Medicare Advantage plans, the share varies greatly by state — ranging from 49 percent in Minnesota to less than 1 percent and 3 percent in Alaska and Wyoming, respectively. Medicare Advantage enrollment continues to be concentrated among a small number of organizations. Beneficiaries in Medicare Advantage Prescription Drug plans (MA-PDs) pay about the same premium ($35 per month) in 2013, on average, as plan enrollees in 2012, with somewhat lower premiums in health maintenance organizations (HMOs) and higher premiums in other plan types. While the vast majority of beneficiaries (98%) have access to a MA-PD with no premium, slightly more than half (55%) of beneficiaries are enrolled in a zero-premium plan in 2013, varying by plan type and locale. All Medicare Advantage plans have a limit on out-of-pocket spending, and nearly half of all Medicare Advantage enrollees are in a plan with a limit at or below $3,400 per year.

The analysis is authored by researchers at Mathematica Policy Research Inc. and the Kaiser Family Foundation.

http://kff.org/medicare/issue-brief/medicare-advantage-2013-spotlight-enrollment-market-update/

Retrospective Chart Reviews now Medicare Fraud?

Kameron Gifford, CPC – 6/8/2013

The U.S. government has shown again this week that they are serious about finding and prosecuting Medicare fraud.  Health plans who participate with the Medicare Advantage program continue to be a primary target for both OIG and CMS auditors, and this pressure is sure to increase with new incentives for Whistleblowers in 2014. The focus on due diligence and oversight has never been greater than it is today. The Department of Justice has been relentless in their pursuit of “accountability” and every summary judgment re-emphasizes the responsibility of compliance among all “down-stream entities”.

In this climate of regulatory reform, healthcare companies must strengthen their internal auditing and compliance programs to comply with current interpretations of these new laws. The “old way” of doing things isn’t just bad business anymore, now it can mean civil and/or criminal penalties. The expectation is that of knowledge and ignorance is no longer a defense.

New Risks in Retrospective Chart Reviews

Historically, Medicare Advantage programs have performed retrospective chart reviews to submit missing diagnoses to Medicare. Health plans routinely contract with coding companies to review the medical records of their members for diagnoses that are properly documented. These properly documented codes are then submitted to CMS as corrections. But what about the original claims submitted by the physician? Are these diagnoses codes being verified for compliance?  If not, this might be considered fraud.   

In a recent settlement agreement between SCAN and the US government, SCAN agreed to pay more than $300 million to settle allegations of “upcoding” among other things. This case represents the first time that this “standard practice” of retrospective chart reviews had ever been challenged in a court of law. The practice of engaging in chart reviews for the sole purpose of adding codes violates the federal rules of the Medicare Advantage program. By not providing the coding contractors with original claims data, the initiative will never result in less diagnoses or a reduction in revenue. 

Consider this article in the LA Times written 8/24/2012:

"The alleged manipulation of those patient risk scores was a key part of the federal whistle-blower suit against SCAN. Separately, SCAN agreed to pay $320 million to resolve allegations that it was overpaid by the state's Medi-Cal program, which serves the poor and disabled. SCAN denied wrongdoing in that settlement as well."
"Federal prosecutors didn't allege any fraud by SCAN. But Susan Hershman, an assistant U.S. attorney in Los Angeles, said investigators concurred that SCAN didn't share certain information with Medicare that would have reduced payments."
 (http://articles.latimes.com/2012/aug/24/business/la-fi-medicare-loss-risks-20120825)

Implications for MRA Programs

• Retrospective Audits Must Be Dual Purpose –
• Verification of previously submitted codes in addition to catching “missing” codes.
• Use a Third Party for MRA Education –
•  Transparency is your most valuable resource.
• Invest in the Resources that you have –
• Educate everyone, knowledge is power.

Empirical Risk Management can help you identify risks in your MRA process, make recommendations and provide quality education for your entire organization.

Initiating Change from the Initial Point of Contact www.ermconsultinginc.com

IRS Examples of Healthcare Fraud Investigations - Fiscal Year 2013 -

Examples of Healthcare Fraud Investigations - Fiscal Year 2013

Examples of Healthcare Fraud Investigations - Fiscal Year 2013

The following examples of healthcare fraud investigations are written from public record documents on file in the court records in the judicial district in which the cases were prosecuted.
Former Nigerian Fugitive Sentenced for Health Care Fraud and Money Laundering
On May 10, 2013, in Houston, Texas, Godwin Chiedo Nzeocha, a naturalized United States citizen originally from the Federal Republic of Nigeria, was sentenced to 109 months in prison and ordered to pay more than $26 million in restitution to Medicare and Medicaid, jointly with his co-conspirators. In addition, Nzeocha agreed to forfeit $1,098,320 to the United States. Nzeocha pleaded guilty on October 19, 2012 to one count of conspiracy to commit health care fraud and one count of money laundering. According to court documents, Nzeocha left the United States in 2009 to avoid arrest after receiving a telephone call from a City Nursing co-conspirator the day Umawa Imo, owner of City Nursing Services of Texas Inc., was arrested. Nzeocha had an agreement with Imo to sign his name on City Nursing patient documents as the provider of physical therapy services that he knew he was not qualified to authorize. The documents included blank treatment data forms, progress notes and daily physical therapy records. Nzeocha further admitted to knowing Imo was buying Medicare beneficiary information from recruiters and paying Medicare beneficiaries cash in order to bill for physical therapy services that were not provided. Nzeocha received approximately $1,098,320 from City Nursing. Between December 3, 2007 and June 26, 2009, when Nzeocha worked at City Nursing, the company billed Medicare and Medicaid for approximately $35,819,508 worth of physical therapy services that were not provided and received approximately $26,233,122 as payment for those services from Medicare and Medicaid. Imo was sentenced in October 2011 to 327 months in prison.
Leader of Medicaid Fraud Conspiracy Sentenced for Fraud and Money Laundering
On May 6, 2013, in Statesville, N.C., Betty Ann Cook, of Sparta, N.C., was sentenced to 40 months in prison, two years of supervised release and ordered to pay $325,820 in restitution. On April 25, 2012, Cook pleaded guilty to one count of health care fraud conspiracy and one count of money laundering conspiracy. According to court documents, Cook was the owner of Families First Home Health Care, a home health care company located in Alleghany Co., N.C. Cook’s company was enrolled with Medicaid to provide personal care services to Medicaid recipients. These services are provided by a home health aide in the recipient’s home. From December 2006 to about October 2010, Cook participated in a scheme to defraud Medicaid by submitting false and fraudulent claims to Medicaid seeking reimbursement for patient care services that were either not provided, not authorized by a physician, or were not based upon a valid in-home eligibility assessment performed by a qualified registered nurse, as required by Medicaid policy.
Ohio Doctor Sentenced on Health Care Fraud and Tax Charges
On March 25, 2013, in Toledo, Ohio, Darrell A. Hall, a medical doctor, was sentenced to 60 months in prison. Hall pleaded guilty to conspiracy to distribute a controlled substance, health care fraud and a tax count. According to court documents, Hall was licensed to practice medicine and operated a practice under the name “EDM Health Services, LLC.” He was also a registered provider to Ohio Medicaid, which provides free health benefits to qualified low-income Ohio residents. Between August 2008 through May 2009, Hall conspired with others to distribute 1,300 pills of oxycodone for no legitimate medical purpose. In addition, between January 2007 and December 2009, he fraudulently billed Ohio Medicaid in the amount of $78,113. Hall also failed to pay $97,384 in taxes that he owed to the IRS on behalf of EDM Health Services, LLC, between 2007 and 2010.
Doctor Sentenced for Health Care Fraud and Tax Evasion
On March 1, 2013, in Wheeling, W.Va., Barton Joseph Adams, of Parkersburg, W.Va., was sentenced to 50 months in prison for health care fraud and tax evasion.  Adams was also ordered to forfeit $3,724,721 to the federal government and to pay $3,136,293 in restitution to various healthcare providers, including Medicare and Medicaid. According to court documents, Adams, a doctor of osteopathic medicine, owned and operated “Interventional Pain Management” in Vienna, W.Va. Adams previously admitted to making fraudulent claims for health care proceeds and to willfully attempting to evade taxes. Josephine Adams, the wife of Dr. Adams, was convicted of assisting her husband in the laundering of nearly $4 million dollars of health care fraud proceeds. The evidence presented showed that the fraud proceeds were first deposited into accounts in West Virginia and then were moved into accounts around the United States before being placed into accounts in Canada, China and the Philippines.
Texas Podiatrist Sentenced for Health Care and Tax Fraud
On January 31, 2013, in Sherman, Texas, Shannon Gallentine, of Maypearl, Texas, was sentenced to 24 months in prison and ordered to pay restitution in the following amounts: $407,942 to the IRS, $254,377 to Medicare, $110,622 to Medicaid, and $26,628 to Blue Cross Blue Shield. Gallentine pleaded guilty on May 10, 2012, to one count of health care fraud and one count of failing to file an income tax return. According to court documents, from January 2004 through May 2007, Gallentine, a podiatrist, owned and operated Ambulatory Foot Care in Lancaster, Texas. During this time, Gallentine submitted false and fraudulent claims to Medicare seeking reimbursement for procedures he did not perform. As a result of these false claims, Gallentine received in excess of $365,000 to which he was not entitled. Additionally, Gallentine willfully failed to file federal income tax returns for calendar years 2004 and 2005.
Florida Chiropractor Sentenced for Conspiracy to Commit Mail Fraud in Connection with Staged Accident Scheme
On January 31, 2013, in Miami, Fla., Jennifer Adams, of Boca Raton, was sentenced to 54 months in prison, three years of supervised release and ordered to pay $1,920,424 in restitution. Adams, a chiropractic doctor, pleaded guilty to a one-count Information charging her with conspiring with others to commit mail fraud for her role in a staged accident fraud scheme. According to court documents, to execute the fraud scheme, recruiters sought out drivers and their friends and family members to participate in staged accidents.  Accident participants were directed by the recruiters to chiropractic clinics that were controlled by co-defendants.  Adams agreed to place her name on the corporate paperwork for two clinics, thus utilizing her status as a licensed chiropractic physician, to allow the clinics to bill insurance companies directly for claims without obtaining additional licensure from the State of Florida. Adams initially believed the clinics to be operating legitimately. Sometime thereafter, Adams became aware that her license and status as a chiropractor was being used to fraudulently submit claims to insurance companies. Adams realized these patients did not require the medical treatment they sought. Adams continued to work at both clinics signing prescriptions for plans of treatment that she knew were not medically necessary and that she knew were being submitted for reimbursement to numerous insurance companies.  From the time that Adams was told about the fraud until the clinics were closed by law enforcement, the clinics submitted fraudulent claims that resulted in more than ten insurance companies making total payments of $1,920,424.
California Doctor Sentenced for Role in Medicare Scam
On December 17, 2012, in Los Angeles, Calif., Dr. Kenneth Thaler, of Westminster, was sentenced to 12 months in prison and ordered to pay approximately $11 million in restitution to the Medicare program. According to court documents, Thaler admitted homeless patients to the Tustin Hospital and Medical Center after they had been driven from “Skid Row” in downtown Los Angeles as part of a Medicare fraud scheme. Thaler admitted approximately 60 patients per month, including some who did not require hospitalization. The patients were recruited by marketers who were being paid kickbacks by recruiters such as Estill Mitts to refer homeless Medicare and Medi-Cal beneficiaries for in-patient hospital stays. After Thaler admitted these patients, he and the hospital billed Medicare and Medi-Cal for in-patient services, even if it was not medically necessary for the patient to be hospitalized. Mitts who operated a center that recruited homeless people to receive unnecessary health services pleaded guilty in September 2008 to conspiracy to commit health care fraud, money laundering and tax evasion. He is awaiting sentencing.
Defendant Sentenced in Multi-Million Dollar Health Care Fraud Case
On November 5, 2012, in Houston, Texas, Tony Nnonso Obi, a naturalized U.S. citizen from the Federal Republic of Nigeria, was sentenced to 41 months in prison for his role in a massive health care fraud that billed the Medicare and Medicaid programs for more than $45 million. Obi pleaded guilty in August 2012 to one count of conspiracy to commit health care fraud and one count of money laundering. As part of his plea, Obi admitted entering into an agreement with Umawa Imo, the owner of City Nursing, to receive 15 percent of the money City Nursing obtained from Medicare for services billed on individuals referred by Obi. Imo paid Obi $1,051,425. Imo is currently serving more than 27 years in prison for his role in the conspiracy.
Michigan Physical Therapist Sentenced on Health Care Fraud and Money Laundering Charges
On October 29, 2012, in Grand Rapids, Mich., Chyawan Bansil, a physical therapist from Farmington Hills, Michigan, was sentenced to 13 months prison, one year of supervised release, and ordered to pay almost $250,000 in back taxes. In addition, Bansil forfeited over $500,000 in assets which had been seized by the government and paid an additional $2.25 million dollars to resolve related civil claims under the False Claims Act. Bansil will also be excluded from participating with Medicare and Medicaid for a minimum of five years. According to court documents, between February 2007 and January 2012, Bansil defrauded Medicare, Medicaid, and Blue Cross Blue Shield of Michigan of more than $1 million by causing those programs to be billed for expensive nerve conduction studies and needle electromyography tests that Bansil did not perform. Bansil was also laundering the proceeds of his fraud scheme in order to avoid taxes.
 

Physician Pleads Guilty to Health Care Fraud Charges for "falsely recording severity of patients illnesses"

            
Defendant is the Third Cardiologist Nationwide to be Criminally Prosecuted for Health Care Fraud Related to the Placement of Heart Stents

U.S. Attorney’s Office June 05, 2013

Eastern District of Kentucky (859) 233-2661

FRANKFORT—A London, Kentucky cardiologist pleaded guilty to charges that he falsely recorded the severity of patients’ illnesses in order to receive payment for numerous heart procedures.
Sandesh Rajaram Patil, 51, a former cardiologist at St. Joseph’s Hospital in London, admitted Tuesday in Frankfort to making false statements regarding the placement of heart stents. Stents are metal tubes surgically inserted into a patient’s arteries in order to improve blood flow.
Patil reached an agreement with the U.S. Attorney’s Office to serve a prison term between 30 and 37 months, pending a judge’s approval. Patil is scheduled for sentencing on August 27, 2013. St Joseph’s hospital has repaid the government $256,800 for cardiac stent procedures that Patil falsely submitted for reimbursement in 2009 and 2010.
Patil is the third cardiologist in the nation and the first in Kentucky to be federally prosecuted for health care fraud related to the placement of heart stents.
“Dr. Patil violated the public’s trust in physicians,” said Kerry B. Harvey, U.S. Attorney for the Eastern District of Kentucky. “Both patients and the entities that pay for medical services trust that our physicians will accurately and honestly assess a patient’s medical condition. We will aggressively pursue any physician or provider that breaches this trust and places their own financial well-being ahead of the well-being of the patients.”
Under federal law, Medicare and Medicaid reimburse physicians for procedures that are deemed medically necessary. For a cardiac stent procedure to qualify as a medical necessity, it is generally accepted that a patient must have at least 70 percent blockage of an artery and symptoms of blockage. Patil admitted that he placed stents in arteries that had substantially less than 70 percent blockage. Patil nonetheless recorded blockage of 70 percent or more in patient documents to guarantee payment from Medicare and Medicaid.
Kerry B. Harvey, U.S. Attorney for the Eastern District of Kentucky; Perrye Turner, Special Agent in Charge, Federal Bureau of Investigation; and Jack Conway, Kentucky Attorney General, jointly announced the plea.
The investigation was conducted by the Federal Bureau of Investigation, the Kentucky Attorney General’s Medicaid Fraud Abuse and Control Unit, and the Department of Health and Human Services.

GOP congressman pushes for ‘patient-centered’ health law

By Tom Howell Jr.

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The Washington Times

Wednesday, June 5, 2013

Rep. Tom Price, Georgia Republican and a physician, says his health care plan won’t put the government “in charge of a doggone thing.” (Associated Press)

A Georgia congressman said Wednesday that House Republicans will redouble efforts to replace President Obama’s health care law with a “patient-centered” alternative that uses tax breaks to make insurance affordable without imposing mandates on Americans.

Rep. Tom Price, a Republican and a doctor, said he will introduce the “third iteration” of his bill to replace the Affordable Care Act as soon as this week.

Besides using the tax code to put health coverage within reach for poorer citizens, he said his legislation would let people roll over their health insurance from employer to employer, allow people with high-risk diagnoses to pool together for more price leverage and continuity in their coverage, and reduce unnecessary medical services by reforming malpractice litigation.

“You can do all of those things without putting the government in charge of a doggone thing,” he said during a wide-ranging breakfast hosted by The Christian Science Monitor in downtown Washington.

He outlined the legislation in an attempt to prove that Republicans can outline specific health care goals and not just lambast Mr. Obama’s overhaul.

Mr. Price’s alternative bill, like every attempt to repeal or replace “Obamacare,” could gain traction in the Republican-led House but will face an uphill battle as long as Democrats control the Senate and White House.

House Minority Leader Nancy Pelosi and other top Democrats have needled House Republicans over their repeated efforts to scrap the law. The chamber’s majority party has called more than 30 votes to repeal all or parts of the law, including one last month that is sure to die on the legislative vine.

“As Speaker [John A.] Boehner has said, the Affordable Care Act is the law of the land,” Pelosi spokesman Drew Hammill said Wednesday. “The American people want solutions from their representatives in Congress, not more silliness. It’s time to drop the partisan games and focus on economic growth and jobs for the middle class.”

But Mr. Price, echoing a now-famous comment from Senate Finance Committee Max Baucus, Montana Democrat and key author of the health care law, said Mr. Obama’s reforms are heading for a “train wreck.”

“I think what we need to do is pull the emergency brake before the wreck occurs,” he told reporters.

Mr. Price said Congress also is equipped to effectively take on two of the most pressing issues on Capitol Hill — deficit reduction and immigration reform.

On the latter, he said he prefers the piecemeal, or “sequential” approach that is favored by House Judiciary Chairman Bob Goodlatte, Virginia Republican, as opposed to comprehensive efforts underway in the Senate.

He said Congress, despite its partisan rancor, can craft meaningful tax reform and reach a deal on how to reduce the federal deficit, now that both chambers have passed budget plans.

“The mechanism in place allows us to move to the next step, which we haven’t been able to do in the last four years,” he said, noting Budget Chairman Paul Ryan, Wisconsin Republican, and Senate Budget Chairwoman Patty Murray, Washington Democrat, are meeting with “great regularity” to set parameters around a budget conference between the parties so it’s “not just a free-for-all.”

In Mr. Price’s view, a “maturing and coalescing” of the GOP conference has allowed its members to get passed their perceived low-point around New Year’s Day, when fractures among the party’s establishment and a young, conservative wing threatened to derail negotiations on the “fiscal cliff.”

He said he would prefer to settle the nation’s budget issues before they reach the debt ceiling once again. That way, he said they would not be not in a crisis mode, “which tends to be the time when Washington makes the least-responsible decisions.”

“I’m an eternal optimist,” Mr. Price said, “so I always believe things are possible, even in this town.”

Arizona insurers must pay for telemedicine

Angela Gonzales

Senior Reporter-Phoenix Business JournalJun 4, 2013, 6:00am MST

Gov. Jan Brewer has signed the Telemedicine Reimbursement Parity Act into law, requiring telemed services in rural areas of Arizona to be covered by health insurance.

Beginning in 2015, insurers must cover services provided through the telemedicine service programs if the insurers pay for those same services when they are provided in a traditional clinic or hospital setting.

The Arizona Legislature established the Arizona Telemedicine Program in 1996, which now links 70 Arizona communities at 160 sites, said Dr. Ronald Weinstein, co-founder and director of the program.

“Our telemedicine program is a critical link to health care,” he added. “We primarily are devoted to improving access to specialized medical care throughout the state of Arizona.”

The new law defines telemedicine services as the delivery of health care, diagnosis, consultation and treatment, and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient.

Kathi Beranek, manager of government relations and public policy for Blue Cross Blue Shield of Arizona, said BCBS worked closely with advocates on the terms of the bill.

“Looking toward 2015, the bill will allow more people, especially in rural communities, access to better care combined with potential cost savings,” she said.

Telemedicine Revenues Grew 237 Percent in Five Years, According to a New Kalorama Information Report

PRWeb | June 5, 2013

The telemedicine patient monitoring market grew from 4.2 billion in 2007 to over 10 billion dollars in 2012, according to Kalorama Information. The healthcare market research publisher said that while the market is small, it is fast growing with a large amount of competitors and increasing awareness of effectiveness.

New York, New York (PRWEB) June 05, 2013

The telemedicine patient monitoring market grew from 4.2 billion in 2007 to over 10 billion dollars in 2012, according to Kalorama Information. The healthcare market research publisher said that while the market is small, it is fast growing with a large amount of competitors and increasing awareness of effectiveness. The finding was made in Kalorama Information’s newly published report, “Advanced Patient Monitoring Systems.”

Kalorama defines telemedicine as a patient monitor used outside of an acute healthcare setting that can transmit vital signs or other information to a healthcare professional for interpretation or action, usually from a patient’s home. Two-way communication in audio or video, EMR data transfer advanced diagnostics are among the additional features that some of these devices provide. Unlike the market for systems used in hospitals, this market is more competitive and vendors are fragmented with a fair number of privately held companies. Compatibility between devices and applications is of primary concern. AMD, Philips, Second Opinion Telemedicine, Bosch, LifeWatch are among the many vendors operating in this market.    The aging of the population, increasing healthcare costs, dwindling healthcare resources, advancing technologies, and the proven cost effectiveness of patient monitoring. The report says that sales will be driven in new technologies as older monitoring equipment is replaced by wireless or remote monitors. Growth will increase over the forecast period as compatibility, privacy, and security issues continue to be resolved.

“The home healthcare and remote location health monitoring market is different from the hospital market, in large part because reimbursements are lower or are just beginning to take hold, and for some products are still nonexistent,” said Melissa Elder, Kalorama analyst and the author of the report. “Unit costs will go up as older units are replaced with wireless, handheld, and ambulatory devices.”

Elder adds that home healthcare markets vendors sell lower-priced units than hospital patient monitors but the key for successful vendors will be selling a volume. The report also indicates that the U.S. holds the largest share of the market and will be the battleground for a lot of the regulatory and reimbursement challenges for these technologies. Yet telemedicine is a worldwide market. Switzerland, for example, has prepared the health system for telemedicine options with an advanced IT infrastructure and healthcare staff trained in high-tech medical technology. Economic struggles in many European countries, including Germany, have forced the government to review options to control costs in the healthcare system which will present opportunities for telemedicine. France is facing some of the same issues as other European countries, though there are barriers. A World Health Organization overview of the French healthcare system in noted that providing care using Telemedicine would require a new legal framework. It has since developed new policies to help professionals obtain reimbursement and provide a newer method of healthcare delivery.

Kalorama’s market research study in this market, “Advanced Patient Monitoring Systems”, contains both a global and US market estimate and forecast for advanced remote patient monitoring systems. The report covers key trends in the industry and profiles several key players in the market. The report can be purchased at Kalorama Information at http://www.kaloramainformation.com/Advanced-Remote-Patient-7450566/

About Kalorama Information

Kalorama Information, a division of MarketResearch.com, supplies the latest in independent medical market research in diagnostics, biotech, pharmaceuticals, medical devices and healthcare, as well as a full range of custom research services. We routinely assist the media with healthcare topics. Follow us on Twitter, LinkedIn and our blog.

For the original version on PRWeb visit: http://www.prweb.com/releases/prweb2013/6/prweb10794697.htm

Aetna and Beacon Health Partners, LLP Build Medical Home Program

Published: June 7, 2013 

ReNEW YORK — Aetna (NYSE: AET) and Garden City-based Beacon Health Partners, LLP today announced a new agreement to reward Beacon’s independent practices for operating as Patient-Centered Medical Homes (PCMHs).

“The PCMH model of care is designed to reward physicians for delivering better coordinated, higher quality and more efficient care, which will result in an improved overall value and patient experience for our members,” said David Kobus, Aetna’s senior vice president of Network Management for New York.

A medical home is a team of doctors and clinicians within a medical practice who work together to provide continuous and comprehensive health care for patients. By providing proactive and ongoing attention, rather than episode-based treatment, doctors in a medical home can provide more efficient and more effective care.

“Medical homes can support improvements in care quality, positively impact member health, and reduce medical costs through better efficiency and data sharing,” said Terry Golash, M.D., Aetna senior medical director. “Medical homes allow for improved information exchange and communication among physicians, other care providers, patients and insurers, all of which help enable informed clinical decisions.”

The two-year initiative rewards Beacon for continued and improved patient care coordination and outcomes in categories such as cancer screening measures and diabetic or cardiovascular monitoring and care. Aetna and Beacon also will share data to support appropriate patient care.

Dr. Simon Prince, President of Beacon said, “Doctors often talk about quality, but don’t measure it. One of the key characteristics of the medical home is that it brings rigorous measurement and quality analysis to prove that the best care is being provided, resulting in fewer hospitalizations and medical errors.”

About Beacon Health Partners

Beacon Health Partners, based in Garden City, NY, is a physician-owned Accountable Care Organization (ACO). Made up of primary care physicians and specialists, Beacon’s mission is to improve quality of care through a new, improved care management system that allows greater focus on patient wellness, reducing time spent on more expensive treatments. Beacon has more than 300 physicians dedicated to providing coordinated, efficient, quality patient care at its numerous locations across Long Island, Queens, Brooklyn and Manhattan. The practice uses state-of-the-art systems and electronic medical records to enhance the health of the community. For more information, visit us at www.beaconhealthpartners.com.

About Aetna

Aetna is one of the nation's leading diversified health care benefits companies, serving an estimated 44 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers' compensation administrative services and health information technology services. Aetna’s customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, seewww.aetna.com.

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