Thursday, June 6, 2013

Cuccinelli: IRS Refusing to Release $125 Million Medicare Fraud Settlement to Virginia

June 5, 2013 - 3:46 PM

(CNSNews.com)

A $125-million settlement from the second largest Medicare Fraud case in history is being held up by the IRS, according to Virginia Attorney General Ken Cuccinelli.

A Virginia Medicaid Fraud Control Unit (MFCU) investigation, which found that Abbott Laboratories illegally marketed the seizure drug Depakote for non-approved uses, was concluded when a settlement was reached in September 2011. A final court order was issued in October 2012.

However, $125 million owed to Virginia as part of the plea agreement has yet to be paid, and federal officials place the blame on the IRS.

“Federal officials have refused to release approximately $125 million that is owed to Virginia from a 2012 Medicaid fraud case Attorney General Ken Cuccinelli’s office investigated,” reads a statement from Cuccinelli’s office.

IRS Contractor Denies Having Personal Relationship with IRS Employee in $500 Million Contracting Investigation

(AP Photo)

“Federal officials have said that the IRS has refused to properly fill out post-case paperwork for almost a year, which is holding up the disbursement intended for Virginia law enforcement,” the statement said.

According to Cuccinelli’s office, the IRS and federal government “have known for nearly two years” what Virginia’s fraud unit was owed out of a $198.5 million asset forfeiture, which was part of Abbott’s plea agreement.

The Treasury Department initially blamed the federal budget sequester for why Virginia has not received the money, Cuccinelli said, despite the fact that the funds come from the private sector, to be paid by Abbott Laboratories.

“Now the hold-up is the IRS, which, according to the Treasury Department, refuses to complete its paperwork so the money can be properly distributed,” Cuccinelli said. “The exact amount of the forfeiture was known since September 2011 and finalized in a May 2012 plea agreement.”

“It doesn’t take a year to complete the paperwork,” he said.

Cuccinelli implied that he believes the delay may be related to the recently uncovered scandal at the agency, where conservative groups were targeted and had their applications for non-profit status delayed for up to three years.

U.S. currency. (AP Photo)

“For months, we thought this was just incompetence by the IRS, but with its refusal to properly fill out fairly simple paperwork for an entire year, we are left to wonder if this involves more deliberate motives,” he said. “Virginians need to know that for eight months the administration has been withholding money that is supposed to be used to protect first responders’ lives.”

The attorney general said he intends to use the money for police departments, equipment, training and gang and gun crime reduction programs.

“During the eight months the Treasury Department has been withholding the money, they have been depriving Virginia law enforcement of tools to make their jobs safer,” he said. “The interest alone on Virginia's share of the money in those eight months would have totaled more than a half-million dollars. That interest could have purchased more than 1,000 bulletproof vests for police officers and sheriffs’ deputies.”

The investigation into Abbott Laboratories found that the company was illegally marketing the prescription drug Depakote to treat dementia patients in nursing homes, and for schizophrenia. The drug is intended to treat epileptic seizures.

At the time of this story, the IRS did not respond to a request for comment.

New healthcare model cut even more costs in year two:

By Sharon Begley

NEW YORK | Thu Jun 6, 2013 8:10am EDT

(Reuters) - The nation's largest experiment in delivering medical care in an innovative way has reduced costs and improved the quality of care even more in its second year than in its first, according to the insurance company behind it.

The nonprofit CareFirst BlueCross BlueShield launched its "Patient-Centered Medical Home" program in January 2011 among primary-care providers serving about one-third of its 3.4 million members in Maryland, Washington, D.C., and northern Virginia.

Like other "accountable care organizations" (ACOs), which are centerpieces of President Barack Obama's healthcare reform, the medical home program ties insurance payments to healthcare providers to the quality of care they deliver.

On Thursday, CareFirst reported cost savings of $98 million for the medical home program in 2012, compared with $38 million the year before. Proponents of the model say it shows that "bending the cost curve downward," as Obama described one of the goals of his 2010 healthcare law, is achievable. If innovative models like CareFirst's deliver as promised, it will ease the financial pressures on Medicare, the government health insurance program for the elderly and disabled, and make Obama's healthcare reform more likely to succeed.

"This is a very important finding, that a major health plan is able to achieve savings" of this magnitude, said Dr Elliott Fisher, a health policy expert at the Dartmouth Institute for Health Policy and Clinical Practice and an architect of accountable care organizations.

Medical homes, like other ACOs, induce physicians to coordinate care to make sure patients' prescriptions don't interact adversely, for instance, and to think twice before ordering unnecessary tests. Physicians who reduce costs while hitting quality metrics such as regularly checking a diabetic's eyesight receive awards in the form of higher payments.

In CareFirst's program, that incentive is substantial: a 29 percent bump in physician reimbursement rates. The insurer can afford to be so generous because improving primary care, which accounts for only 6 percent of medical spending, reduces far pricier hospitalizations and specialist visits.

CareFirst's success is likely to accelerate other efforts to move from a traditional fee-for-service model, where the more tests and treatments physicians and hospitals do the more they make, to one that rewards efficiency and quality. Twenty-nine U.S. states now let primary-care providers act as patient-centered medical homes for residents on the Medicaid program for the poor, for instance.

Major insurers including UnitedHealth Group, WellPoint, Aetna, Humana and Cigna are also contracting with physicians to operate under an accountable care model.

BUILDING UP SAVINGS

Skeptics have warned that any savings in programs like medical homes would peter out after their first year, as physicians eliminated the most obvious and easiest-to-cut waste, and that further reductions would cut necessary care.

CareFirst has found otherwise.

One million of its members (almost all employed, with an average age of 42) were in medical homes in 2012, the company reported, and 80 percent of the primary-care providers in CareFirst's network participate in the program. These members' healthcare costs were $98 million (2.7 percent) less than CareFirst projected. In 2011, the savings were 1.5 percent.

Most of the savings came from reduced hospital admissions, less use of emergency rooms and lower spending on drugs, said CareFirst Chief Executive Officer Chet Burrell.

Two-thirds of the 3,600 physicians and nurse practitioners participating in the medical home program earned higher reimbursements from CareFirst in 2012, based on a combination of cost savings (which averaged 4.7 percent) and quality measures. Measuring quality - which also includes having extended office hours and using electronic medical records - keeps doctors from trying to save money by skimping on needed care.

"This is a measurable and meaningful step in the right direction of slowing the rise of healthcare costs," said Burrell.

At primary-care practices that did not earn an incentive award, costs averaged 3.6 percent higher than expected. Their quality scores were also worse, suggesting that wasteful care often goes hand in hand with poor care.

CareFirst's savings are in line with those reported by 10 physician groups across the United States that treated Medicare patients under an accountable care model. Annual savings averaged $114 per patient, researchers led by Fisher reported in the Journal of the American Medical Association last year. But savings reached $532, or 5 percent, for patients eligible for both Medicare and Medicaid.

CareFirst received a grant from the federal Centers for Medicare and Medicaid Services to expand the medical home model to Medicare patients starting July 1. These older Americans "frequently have complex health needs and multiple chronic health conditions," said Burrell, and so "could benefit greatly from the coordinated model of care" in medical homes.

(Reporting by Sharon Begley and Caroline Humer; Editing by Douglas Royalty)

Major Family Practice In Houston says no more Medicare

Posted: Jun 05, 2013 10:48 PM EDTUpdated: Jun 05, 2013 10:48 PM EDT

By Greg Groogan, Special Projects Reporter -

HOUSTON (FOX 26) -

After a quarter century of practicing medicine Dr. Robert Van Zant says it's among the toughest calls he's had to make, but he and fellow physicians at Village Family

Practice are shutting the door to new patients covered by Medicare.

The third largest group of primary care doctors in the Houston area claims the government insurer's red tape and mandate of electronic record keeping very nearly strangled their business, so they had to act.

"New burdens, restrictions on medicines we can prescribe, restrictions on labs we can do, surgeries we can refer for," said Van Zant.

and then there's Medicare's compensation which for Doctors hasn't risen substantially since 2001.

"Can you imagine going to the auto workers and telling them you are not going to get a raise in 13 years. It would not happen," said Van Zant.

and yet in 2014 Van Zant says physicians will again face a 30 percent cut in the rate Medicare pays for their services.

That's not to mention the unclear impact of the Affordable Care Act known as Obamacare. Van Zant predicts a crisis.

"I think some of the burdens of the Affordable Care Act are really going to strike home next year there are expenses and surprises in that that we haven't even dreamt of yet, but the Affordable Care Act is going to be a financial

disaster and its certainly not going to help Medicare," said Van Zant.

Turns out Van Zant and the doctors at Village have plenty of company, the Texas Medical Association says 40 percent of the state's physicians have stopped taking new Medicare patients.

"It brought this practice to a crawl," said Van Zant.

For its part Medicare claims the problem is not widespread reporting fewer than 10,000 doctors across the country have opted out of the program in the past two years.

Van Zant says Village Family Practice treats more than 8,000 existing patients currently on Medicare and will continue to do so.

Final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act) related to the Small Business Health Options Program (SHOP)

Summary

This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act) related to the Small Business Health Options Program (SHOP). Specifically, this final rule amends existing regulations regarding triggering events and special enrollment periods for qualified employees and their dependents and implements a transitional policy regarding employees' choice of qualified health plans (QHPs) in the SHOP.

Dates

These regulations are effective on July 1, 2013.

For Further Information Contact

Leigha Basini at (301) 492-4307.

Supplementary Information

I. Executive Summary

Beginning in 2014, individuals and small businesses will be able to purchase private health insurance through competitive marketplaces, called Affordable Insurance Exchanges or “Exchanges” (also called Health Insurance Marketplaces). Section 1311(b)(1)(B) of the Affordable Care Act contemplates that in each State there will be a SHOP that assists qualified employers in providing health insurance options for their employees. The final rule, Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers (Exchange Establishment Rule), ⁽¹⁾as modified by the Notice of Benefit and Payment Parameters for 2014, ⁽²⁾sets forth standards for the administration of SHOP Exchanges. In this rule, we finalize provisions proposed in the Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program Notice of Proposed Rule Making, ⁽³⁾which amends some of the standards established in the Exchange Establishment Rule.

In the Exchange Establishment Rule, we established standards for special enrollment periods for people enrolled through an individual market Exchange, and provided that, in most instances, a special enrollment period is 60 days from the date of the triggering event. See 45 CFR 155.420. We also made these provisions applicable to SHOPs, at § 155.725(a)(3). In the proposed rule we proposed and this final rule amends, the special enrollment period for the SHOP to 30 days for most applicable triggering events, so that it aligns with the special enrollment periods for the group market established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). ⁽⁴⁾To further align the SHOP provisions with HIPAA, we also proposed that if an employee or dependent becomes eligible for premium assistance under Medicaid or the Children's Health Insurance Program (CHIP) or loses eligibility for Medicaid or CHIP, this would be a triggering event, and the employee or dependent would have a 60-day special enrollment period to select a QHP. This triggering event had previously been inadvertently omitted from the regulations because it applies only to group health plans and health insurance coverage in the group market. We also proposed to make a conforming change to § 156.285(b)(2), so that this section references the SHOP special enrollment periods in a way that is consistent with our proposed changes to § 155.725.

In the Exchange Establishment Rule, we also set forth the minimum functions of a SHOP, including that the SHOP must allow employers the option to offer employees all QHPs at a level of coverage chosen by the employer, and that the SHOP may allow employers to offer one or more QHPs to qualified employees by other methods. We proposed and are now finalizing the following transitional policy. For plan years beginning on or after January 1, 2014 and before January 1, 2015, a SHOP will not be required to permit qualified employers to offer their qualified employees a choice of QHPs at a single level of coverage, but will have the option of doing so. Federally-facilitated SHOPs (FF-SHOPs) will not exercise this option, but will instead allow employers to choose a single QHP from the choices available in FF-SHOP to offer their qualified employees. This transitional policy is intended to provide additional time to prepare for an employee choice model and to increase the stability of the small group market while providing small groups with the benefits of SHOP in 2014 (such as a choice among competing QHPs and access for qualifying small employers to the small business health care tax credit). We also proposed changes to the effective date of the SHOP premium aggregation function set forth at § 155.705(b)(4) in the Exchange Establishment Rule consistent with this transitional policy, which we are finalizing in this rule.

For the reasons set forth in the preamble, the Department of Health and Human Services amends 45 CFR parts 155 and 156 as set forth below:

Regulatory Text

Part 155 Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act

1. The authority citation for part 155 continues to read as follows:

Authority:

Title I of the Affordable Care Act, sections 1301, 1302, 1303, 1304, 1311, 1312, 1313, 1321, 1322, 1331, 1334, 1402, 1411, 1412, 1413.

2. Section 155.705 is amended by revising paragraphs (b)(2) through (4) to read as follows:

§ 155.705 Functions of a SHOP.

* * * * *

(b) * * *

(2) Employer choice requirements. With regard to QHPs offered through the SHOP for plan years beginning on or after January 1, 2015, the SHOP must allow a qualified employer to select a level of coverage as described in section 1302(d)(1) of the Affordable Care Act, in which all QHPs within that level are made available to the qualified employees of the employer.

(3) SHOP options with respect to employer choice requirements. (i) For plan years beginning before January 1, 2015, a SHOP may allow a qualified employer to make one or more QHPs available to qualified employees:

(A) By the method described in paragraph (b)(2) of this section, or

(B) By a method other than the method described in paragraph (b)(2) of this section.

(ii) For plan years beginning on or after January 1, 2015, a SHOP:

(A) Must allow an employer to make available to qualified employees all QHPs at the level of coverage selected by the employer as described in paragraph (b)(2) of this section, and

(B) May allow an employer to make one or more QHPs available to qualified employees by a method other than the method described in paragraph (b)(2) of this section.

(iii) For plan years beginning before January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer the choice to make available to qualified employees a single QHP.

(iv) For plan years beginning on or after January 1, 2015, a Federally-facilitated SHOP will provide a qualified employer a choice of two methods to make QHPs available to qualified employees:

(A) The employer may choose a level of coverage as described in paragraph (b)(2) of this section, or

(B) The employer may choose a single QHP.

(4)(i) Premium aggregation. Consistent with the effective dates set forth in paragraph (b)(4)(ii) of this section, the SHOP must perform the following functions related to premium payment administration:

(A) Provide each qualified employer with a bill on a monthly basis that identifies the employer contribution, the employee contribution, and the total amount that is due to the QHP issuers from the qualified employer;

(B) Collect from each employer the total amount due and make payments to QHP issuers in the SHOP for all enrollees; and

(C) Maintain books, records, documents, and other evidence of accounting procedures and practices of the premium aggregation program for each benefit year for at least 10 years.

(ii) Effective dates. (A) A State-based SHOP may elect to perform these functions for plan years beginning before January 1, 2015, but need not do so.

(B) A Federally-facilitated SHOP will perform these functions only in plan years beginning on or after January 1, 2015.

* * * * *

3. Section 155.725 is amended by:

A. Amending paragraph (a)(1) by adding “and” at the end of the paragraph.

B. Amending paragraph (a)(2) by removing “; and” and by adding a period in its place at the end of the paragraph.

C. Removing paragraph (a)(3), and

D. Adding paragraph (j).

The addition reads as follows:

§ 155.725 Enrollment periods under SHOP.

* * * * *

(j)(1) Special enrollment periods. The SHOP must provide special enrollment periods consistent with this section, during which certain qualified employees or a dependent of a qualified employee may enroll in QHPs and enrollees may change QHPs.

(2) The SHOP must provide a special enrollment period for a qualified employee or dependent of a qualified employee who:

(i) Experiences an event described in § 155.420(d)(1), (2), (4), (5), (7), (8), or (9);

(ii) Loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a State child health plan under title XXI of the Social Security Act; or

(iii) Becomes eligible for assistance, with respect to coverage under a SHOP, under such Medicaid plan or a State child health plan (including any waiver or demonstration project conducted under or in relation to such a plan).

(3) A qualified employee or dependent of a qualified employee who experiences a qualifying event described in paragraph (j)(2) of this section has:

(i) Thirty (30) days from the date of a triggering event described in paragraph (j)(2)(i) of this section to select a QHP through the SHOP; and

(ii) Sixty (60) days from the date of a triggering event described in paragraph (j)(2)(ii) or (iii) of this section to select a QHP through the SHOP;

(4) A dependent of a qualified employee is not eligible for a special election period if the employer does not extend the offer of coverage to dependents.

(5) The effective dates of coverage are determined using the provisions of § 155.420(b).

(6) Loss of minimum essential coverage is determined using the provisions of § 155.420(e).

Part 156 Health Insurance Issuer Standards Under the Affordable Care Act Including Standards Related to Exchanges

4. The authority citation for part 156 continues to read as follows:

Authority:

Title I of the Affordable Care Act, sections 1301-1304, 1311-1312, 1321, 1322, 1324, 1334, 1341-1343, and 1401-1402, Pub l. 111-148, 124 Stat. 119 (42 U.S.C. 18042).

5. Section 156.285 is amended by revising paragraph (b)(2) to read as follows:

§ 156.285 Additional standards specific to SHOP.

* * * * *

(b) * * *

(2) Provide special enrollment periods as described in § 155.725(j);

* * * * *

Dated: May 13, 2013.

Marilyn Tavenner,

Administrator, Centers for Medicare & Medicaid Services.

Approved: May 15, 2013

Kathleen Sebelius,

Secretary, Department of Health and Human Services.

[FR Doc. 2013-13149 Filed 5-31-13; 11:15 am]

BILLING CODE 4120-01-P

http://www.regulations.gov/#!documentDetail;D=CMS_FRDOC_0001-1228

Innovation in healthcare needed, experts say

Jun 5, 2013, 04.01PM IST TNN

[ Umesh Isalkar ]

PUNE: Indian healthcare system needs innovation and collaboration, rather than confrontation, say experts. The health sector carries huge potential for all the stakeholders like patient groups, government, hospitals, pharmaceutical companies as well as the non governmental organisations (NGO). People need services and they need it at a lower cost. It cannot happen without cooperation from all the sectors, they say.

Pharmaceutical sector has a major role to play in healthcare innovation. However, the pharmaceutical companies are in a fix due to increasing development costs and decreasing margins. Sundeep Kumar, head, corporate and public affairs, Novartis said, "The pharma industry remains concerned about patients' access to healthcare and are committed to working with the government of India and other stakeholders to find sustainable solutions. Still, product innovation in pharma industry is extremely capital intensive."

"To sustain this process, pharma companies like any other business have to recover the costs. In a country like India, where 85% of the healthcare costs are paid by the end consumer, to reduce this burden, innovative models of partnership amongst government, insurance companies and pharmaceutical companies need to be worked out in order to provide better access," Kumar said.

Recently, government and a pharmaceutical company have together developed a "Rotavac" vaccine that can save millions of children. This public private partnership sets an example for the rest of the industry; they can follow suit and help in countering the cost of healthcare services. Collaboration of government, patient groups, NGOs and insurance companies could be the game changer for the country.

Amit Kapoor, honorary chairman at Institute for Competitiveness India, said, "India needs to support and incentivise an innovation driven environment. It needs to explore business models that tackle issues specific to India including PPP, social entrepreneurship and patient assistance programmes. Innovation in healthcare can be a game changer; however, cost of innovation needs to be borne by someone, which could be government too."

Vinod Kumar, emeritus professor, department of medicine, St Stephens Hospital, Delhi and president emeritus, Alzheimer's and Related Disorders Society of India, said, "India's population is rapidly ageing and this aging population requires affordable, accessible and quality public health services, innovative healthcare financing and preventive measures like lifestyle modification, and better hygiene. Most importantly, Alzheimer's patients and patients with related disorders need new treatment options to improve quality of life and cure disease. In order for Indian patients to realise such benefits, India must create an innovative environment to support greater clinical research for these cures."

Paladina Health Opens Its 35th Innovative Primary Care Clinic

Employer-sponsored medical home model delivers higher-quality, lower-cost health care to employers and individuals

DENVER--(BUSINESS WIRE)--Paladina Health, LLC, an innovative employer-sponsored medical home health care provider, today announced the opening of the 35th clinic in its growing nationwide network. Located at 32275 32nd Ave. S. in Federal Way, Wash., the clinic is Paladina Health’s^TM second in the state.

“Paladina Health is determined to lead the way to better, more affordable care that helps employers attract, support and retain healthier employees.”

Paladina Health’s employer-sponsored medical home model helps self-insured employers comprehensively manage the health and health care cost of their employees and employees’ families, leading to as much as 15 percent total cost savings.

These results are achieved through a physician-access model designed to deliver a differentiated employee benefit as Paladina Health's physicians proactively work with patients to improve their health and provide quality care in an easily accessible location.

The model’s components include:

24/7 employee access to a personal physician, who is available via mobile phone and is held accountable for their patients’ satisfaction, engagement and health;
Convenient clinics that are located at an employer worksite or at a shared, near-worksite location;
A broad number of medical services, including primary, preventive and basic urgent care provided for a low fixed monthly fee; and
Assistance to patients in navigating specialty and hospital-based care to high-quality, low-cost providers as needed.

“Health care in the U.S. has to change,” said Rebecca Steinfort, Paladina Health Chief Operating Officer. “Paladina Health is determined to lead the way to better, more affordable care that helps employers attract, support and retain healthier employees.”

Paladina Health’s Tacoma, Wash., clinic has shown significant improvements in total health care costs while also driving high employee satisfaction, loyalty and productivity. The company plans to release a case study showing the Tacoma clinic’s health results data later this month.

Like the Tacoma clinic, the Federal Way clinic will be available both to employer groups and to individuals who want to purchase a membership directly.

Paladina Health currently operates in 12 states, with some of its clinics and practices currently operating under the name ModernMed®.

Paladina Health is a subsidiary of $9 billion health care services company DaVita HealthCare Partners®. Part of DaVita HealthCare Partners’ strategy includes developing innovative healthcare delivery models with the goal of dramatically improving the cost and quality of healthcare in the United States.

Paladina Health, the Paladina Health logo, DaVita, HealthCare Partners and DaVita HealthCare Partners are trademarks or registered trademarks of DaVita HealthCare Partners Inc. All other trademarks are the property of their respective owners.

About Paladina Health

Paladina Health’s mission is to provide unbiased advocacy for patients and employers in their quest to improve access to high-quality, affordable healthcare. Paladina Health strives to redefine employer-provided health care in the United States. More information is available at PaladinaHealth.com.

About DaVita HealthCare Partners

DaVita HealthCare Partners, a Fortune 500® company, is the parent company of DaVita and HealthCare Partners. DaVita is a leading provider of kidney care in the United States, delivering dialysis services to patients with chronic kidney failure and end stage renal disease. As of March 31, 2013, DaVita operated or provided administrative services at 1,991 outpatient dialysis centers located in the United States serving approximately 156,000 patients. The company also operated 41 outpatient dialysis centers located in nine countries outside the United States. HealthCare Partners manages and operates medical groups and affiliated physician networks in California, Nevada, Florida and New Mexico in its pursuit to deliver high-quality health care in a dignified and compassionate manner. For more information, please visit DaVitaHealthCarePartners.com.

Medtech CEO Amar Sawhney named among White House's Champions of Change | MassDevice

June 5, 2013 by Arezu Sarvestani

Ocular Therapeutix CEO Amar Sawhney is named a White House "Champion of Change" for his medical device innovations.

Ocular Therapeutix CEO Amar Sawhney with President Barack Obama

Amar Sawhney at a meet-and-greet outside of President Barack Obama's Chicago home.

Serial entrepreneur and Ocular Therapeutix president & CEO Amar Sawhney was named among the White House's Champions of Change for his work in medical devices and "passion for life-saving innovation" and his leadership as an "Immigrant Innovator."

Sawhney, who has more than 120 patents to his name, immigrated from India in 1987 to attend the University of Texas in pursuit of a Master's degree in chemical engineering.

"Unlike many immigrants, I was not fleeing persecution or economic stagnation," Sawhney wrote in a short article about how he came to be a serial medtech entrepreneur, which he characterized as "through a series of happy accidents and some deliberate decisions."

He faced some rather daunting roadblocks on the road to success, least of which was his early inability to get find work because he didn't have a green card. Yet it was precisely that setback that led him to pursue a Ph.D., which "turned out to be a seminal move," Sawhney wrote.

Hear more about Amar Sawhney's journey and unique philosophy at the 2013 MassDevice Big 100 on July 16th.

"My academic advisor and I invented some very cool technology," he wrote. "We invented methods to do super fast chemical reactions to build materials on living cells and tissues, without harming them in the least bit. This opened up some wide new horizons for the field of tissue engineering."

It was during that time that Sawhney was approached by a California venture capital group that offered to launch a company around the technology Sawhney was building.

"I remember thinking then that only in the United States would someone funnel millions of dollars into the idea and dreams of a 25-year-old kid!"

Video: Learn how Sawhney is looking to change the paradigm of eye care at Ocular Therapeutix

Sawhney went on to develop early surgical sealants that help improve outcomes in patients undergoing brain, lung, cardiac and other surgeries, decreasing scarring and lowering radiation exposure to healthy tissue, among other applications.

"The applications seem to be endless and we are continuing to eagerly solve new challenges each day," he wrote. "I feel humbled and privileged to have the opportunity to do what I do. I realize that nowhere else in the world would I have been able to launch into an entrepreneurial career, the way that I did, except in the United States."

Prior to steering the ship at Ocular Therapeutix, Sawhney founded and was CEO of Confluent Surgical (a biosurgery company acquired by Covidien), the chairman of MarketRx (a pharmaceutical marketing and sales and intelligence provider acquired by Cognizant), and technology founder of Focal, Inc. (acquired by Genzyme) and Access Closure Inc.

News Well, Capitol Hill, MassDevice Big 100

Medtech CEO Amar Sawhney named among White House's Champions of Change | MassDevice

Why a great ICD-10 steering committee is so important

Author Name Jennifer Bresnick | Date June 5, 2013

You can order all your coding workbooks, schedule your physician lectures, hand out ICD-10 lollipops by the dozen, and nag your vendors until you’re blue in the face, but the chances of your hospital being fully prepared for ICD-10 without a strong project plan and central leadership are slim at best. The ICD-10 steering committee is a critical component of a successful conversion plan, and is the best defense against important initiatives slipping through the cracks as hospitals scramble to coordinate end-to-end testing, vendor updates, physician and coder education, and employee buy-in to one of the most frazzling and disgruntling transitions in healthcare.

Why should my hospital have one?

The purpose of the steering committee, executive leadership board, project plan commission, or whatever you want to call it, is to provide a centralized authority to establish a direction and achieve consensus when big decisions have to be made. ICD-10 is a project with a very firm deadline. Plain and simple? You won’t get paid for ICD-9 codes used for services provided on or after October 1, 2014. With the majority of hospitals dragging their feet on implementation, and the compliance date approaching quickly, the only way to galvanize a reluctant organization with hundreds of moving parts is by establishing a board that can plan, delegate, and hold all parties responsible for their various tasks.

“It’s going to take longer than people think,” warns AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, FACHE. “It really does take a village. What we’re finding that there are so many systems that are impacted by this coding change that you have to work together with your entire organization to get you where you need to go.”

Who should be on the committee?

While it’s definitely important to get the thumbs-up from the executive leadership of the hospital, the steering committee shouldn’t just consist of your C-suite. It is vital to bring in representatives from the clinical side, recruit physician champions who are enthusiastic about the project, and make sure you’re keeping your coding staff and IT wizards informed about your progress and concerns.

Project management is the key to a successful transition, and having strong, experienced managers to lead the charge can make all the difference. “There are just so many projects that contribute to your overall ICD-10 approach,” explains Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS, former President of AHIMA who now works with Nuance. “But within each one of those, you need people who are good, strong, solid project managers. You want people who get up in the morning and think project management. They’re the ones who are going to be very disciplined, very structured. So if there’s any slippage in any of those projects, they’re going to know right away.”

A steering committee that represents all the major players in the ICD-10 transition – physicians, coders, financial staff, the IT department, and executive decisions makers – can secure the willingness of participants and craft a targeted, encouraging message for employees who may be hesitant to embrace the changes that ICD-10 will bring.

What should the committee do?

A steering committee should set up sub-committees in charge of the major aspects of ICD-10: coder training, physician education, and technical testing and compliance projects. CMS has released a series of checklists and timelines for each of these areas to help guide organizations to the finish line. The committee should establish benchmarks and meet monthly with representatives to ensure that goals are being met in a timely manner.

Communication is one of the biggest challenges of the transition, and the need for hospital-wide buy-in shouldn’t be underestimated. Appointing physicians or nurses as advocates to help other clinical staff understand what will be required of their documentation habits can help ease fears about massive changes to workflow or patient notes. Checking in with the budget department will also be crucial, as the ICD-10 transition is expected to have a major impact on revenue cycles, and all that staff education is an expensive ordeal. Putting your hospital’s CFO on the committee will ensure that there are no monetary surprises at the end of the day.

Make sure that the committee meets regularly and stays active and engaged in the entire ICD-10 process, including the weeks and months after October 1. Your ICD-10 process isn’t going to end on the implementation date: no one really knows what the impact will be on productivity and claims processing, so you’ll need to keep making adjustments if your coders can only do half as much work as they get used to the new system.

There’s no doubt in anyone’s mind that ICD-10 is going to be a headache. But a strong steering committee that takes charge, engages with stakeholders, and makes the tough decisions can help mitigate the pain. If you’re one of the 25% of hospitals that haven’t taken this vital step yet, consider recruiting some leaders right away in order to prevent a big disaster next fall.

California-based healthcare facility pays $14.1M

June 5, 2013 11:27 AM
By STEPHANIE OSTROWSKI

WASHINGTON (Legal Newsline) – After allegedly violating the False Claims Act, healthcare facility Adventist Health System/West and its affiliated hospital White Memorial Medical center have agreed to pay $14.1 million to settle with the United States and California.

The settlement announced May 3 resolves allegations that Adventist Health physicians referred patients improperly to White Memorial and were compensated. According to the Department of Justice assets were transferred at less than fair market value, including medical and non-medical supplies and inventory.

The compensation the referring physician received from White Memorial violated the Anti-Kickback Act, Stark Statute, and by extension, the False Claims Back according to the United States.

About $11.5 million will be paid to the U.S. Government and the majority will benefit the Medicare Trust Fund. The remaining $2.6 million will be paid to California’s Department of Health Care Services.

“Kickbacks and other unlawful financial arrangements cost taxpayer dollars and undermine the integrity of medical judgments,” said Stuart F. Delery, the Acting Assistant Attorney General for the Civil Division. “The Department of Justice is committed to making sure that physician referrals do not involve payments made in violation of federal law.”

Prohibited by the Anti-Kickback Act is the offering, paying soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid and/or other federally-funded programs.

The Stark Statute prohibits a hospital from submitting claims for referrals made by physicians who have a financial arrangement with the hospital.

Both the Anti-Kickback Act and Stark Statute are intended to ensure that a physician’s medical judgment and decisions are based on the best interest of the patient and not on financial incentives.

“Payouts made by hospitals and clinics – as the government alleged in this case – raise substantial concerns about physician independence and objectivity,” said Ivan Negroni, Special Agent in Charge of the Office of Inspector General, U.S. Department of Health and Human Services San Francisco region. “Taxpayers and vulnerable patients rightfully expect such payments to be investigated and pursued.”

Under the qui tam, or whistleblower, provisions of the False Claims Act, private citizens can bring civil actions on behalf of the United States and share in any recovery. In this case, the whistleblowers will collectively receive $2,839,219.

According to the settlement, White Memorial has entered into a comprehensive five-year Corporate Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services to ensure future compliance with federal health care benefit program requirements.

Adventist Health is headquartered in Roseville, Calif., and operates 19 hospitals and over 150 clinics in California, Hawaii, Oregon and Washington. White Memorial Medical Center is a teaching hospital located in Los Angeles.

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services.

The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $14.2 billion.

The claims settled by this agreement are allegations only.

This entry was posted in California, Federal Government, News, State AGs, States and tagged Adventist Health System/West,Department of Justice, White Memorial Hospital. Bookmark the permalink.

Administration officials plan to announce the new fraud numbers Thursday as they push for more help from seniors in fighting fraud.

Kelly Kennedy, USA TODAY6:47 p.m. EDT June 5, 201

WASHINGTON — The government has revoked the ability of 14,663 providers and suppliers to bill Medicare over the past two years — almost two and a half times the number that had been revoked in the previous two years, new Department of Health and Human Services statistics to be released Thursday show.

In some states, the number of revocations has quadrupled.

"We have always been doing some of this," said Peter Budetti, Center for Medicare Services deputy administrator for program integrity. "But there has been a special focus under the Affordable Care Act."

Administration officials plan to announce the new fraud numbers Thursday as they push for more help from seniors in fighting fraud. One proposed rule would allow people who report fraud to earn up to $9.9 million in reward money in a new fraud-prevention program. Before today, beneficiaries could receive up to $10,000 for tips leading to recovery of fraud money.

A key part of the anti-fraud effort, Budetti said, includes a new, easier-to-read summary statement that allows recipients to see exactly who has billed Medicare with their identification numbers. That's a "landmark change," he said.

"Our best weapon in fighting fraud is our 50 million Medicare beneficiaries," he said. Upping the incentive amount from a possible $10,000 per case to a possible $9.9 million would "attract the kind of attention" the government needs to spotlight the program, Budetti said.

During the past four years, the government has recovered $14.9 billion in Medicare fraud money, due in large part to the 2010 health care law, also known as the Affordable Care Act. The law allowed the government to analyze data to spot indications of fraud and stop paying providers. Budetti explained that all providers had to go through a reapplication process to participate in Medicare.

Those who didn't meet a requirement, had felony convictions, had incorrect addresses or who weren't properly licensed are no longer allowed to bill Medicare. Officials focused on providers in areas that have historically high levels of fraud, such as durable medical equipment, home health care and ambulance services. In the two years before the system was in place, just 6,307 providers and suppliers had their Medicare billing privileges revoked, according to CMS.

However, the program faced pressure from Congress in October when members learned the system had not yet integrated Medicare's payment program.

"The key question is, when will Medicare officials finally have a fully operational and effective anti-fraud system so we can turn off the spigot of fraudulent Medicare payments?" said then-senator Scott Brown, R-Mass. He added that the system was "months late."

At the time, officials said it would be integrated by January. CMS reported in January that the system was saving $3 for every $1 spent in the first year.

The system is now working, Budetti said, although he wants to see it work harder. Last year, seniors called Medicare's fraud hotline to report billing from doctors they had never seen. Using that information, Budetti said they learned of one provider that had sparked calls from 200 to 300 Medicare recipients. In other cases, seniors reported the fraudulent use of their Medicare numbers. Officials then used the system to track providers with a history of using Medicare beneficiary numbers fraudulently.

Budetti said officials are still looking for a good way to reissue beneficiary numbers to the 284,000 people who, according to a report by HHS' inspector general, have had breached or stolen numbers. The numbers tie in to several government systems, such as Social Security, so it's difficult to change them.

In the meantime, the new statements should help, Budetti said. Last year, between 40,000 and 50,000 phone calls to the Medicare hotline were key to fraud investigations, he said.

Last week, HHS Secretary Kathleen Sebelius credited fraud reduction as part of the reason Medicare solvency had been extended by two years in the annual trustees report.

http://www.usatoday.com/story/news/politics/2013/06/05/medicare-revoking-providers-billing-fraud/2393561/