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.

-

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.

Read more here: http://www.heraldonline.com/2013/06/07/4927772/aetna-and-beacon-health-partners.html#storylink=cpy

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USDOJ: Michigan Doctor Sentenced for Role in Medicare Fraud Scheme

Lansing-area resident Dr Paul Kelly was sentenced to 18 months in prison today for his role in a $13.8 million Medicare fraud scheme. 

Acting Assistant Attorney General Mythili Raman of the Criminal Division; United States Attorney for the Eastern District of Michigan Barbara L. McQuade; Special Agent in Charge Robert D. Foley III of the FBI’s Detroit Field Office; and Special Agent in Charge Lamont Pugh III of the United States Department of Health and Human Services, Office of Inspector General’s (HHS-OIG), Chicago Regional Office, made the announcement.  

Kelly, 76, was sentenced by United States District Judge Gerald E. Rosen of the Eastern District of Michigan.  In addition to his prison term, Dr Kelly was sentenced to three years of supervised release and ordered to pay $582,912 in restitution.  

Kelly pleaded guilty on January 10, 2013, to one count of health care fraud.  According to information contained in plea documents, beginning in or around January 2011 and continuing through approximately March 2011, Kelly signed home health care referrals for a home health agency called Moonlite Home Care Inc ., located in Livonia, Mich. Kelly certified Medicare beneficiaries as homebound, a requirement for receiving home health care, when in fact, Kelly had never examined or met the beneficiaries, and they were not homebound. Medicare paid approximately $582,912 for fraudulent home health care claims submitted by Moonlite based on Kelly's referrals. 

This case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the United States Attorney’s Office for the Eastern District of Michigan. This case was prosecuted by Trial Attorney Catherine K. Dick of the Criminal Division’s Fraud Section.

http://7thspace.com/headlines/439149/usdoj_michigan_doctor_sentenced_for_role_in_medicare_fraud_scheme.html

Medlocks convicted of Medicare fraud

NASHVILLE -- A couple accused of defrauding the federal government through the fake Medicare bills has been convicted various charges in connection with the case.

Woody Medlock, Sr., 69, and his wife, Kathy Medlock, 57, of Murfreesboro, who are the former owners of Murfreesboro Ambulance Service, have been convicted by a jury on charges of conspiracy, Medicare fraud, wire fraud, and aggravated identity theft, announced David Rivera, acting U.S. attorney for the Middle District of Tennessee.

A third defendant, Woody “Bubba” Medlock Jr., was acquitted of similar charges. 

According to the evidence presented at trial and the indictment, from 1996 through September 2008, the Medlocks conspired and engaged in a scheme to defraud Medicare and Medicaid by submitting claims for payment for the transportation of patients who were not qualified to receive ambulance transportation. 

Evidence at trial showed that the Medlocks submitted or caused to be submitted, through Murfreesboro Ambulance Service, fraudulent claims totaling more than $1.6 million to Medicare and Medicaid for reimbursement of ambulance transports of patients to and from dialysis treatments.

Testimony at trial further showed that these fraudulent claims falsely represented that patients were on stretchers when the patients were actually transported in the front seat of the ambulance or in a seat in the back of the ambulance and were not on stretchers. 

Fraudulent claims also stated that patients were transported individually when in fact, two patients had been transported simultaneously in one ambulance. 

Both defendants were convicted of two counts of aggravated identity theft for using the names and Medicare numbers of patients without lawful authority in submitting claims. 

Kathy Medlock was also convicted of an additional count of aggravated identity theft for use of a doctor’s name in forging and submitting multiple medical necessity forms as part of a Medicare audit. 

“This case represents another example that this office will hold individuals accountable when they steal from health care programs intended to help the elderly and the most needy citizens,” Rivera said. “This office, along with our law enforcement partners at the U.S. Department of Health and Human Services, the Federal Bureau of Investigation, and the Tennessee Bureau of Investigation, will relentlessly pursue those who choose to defraud the Medicare and Medicaid programs.”

“The Medlocks were running a taxpayer-funded taxi service disguised as an ambulance company,” said Derrick L. Jackson, the special agent in charge at the U.S. Department of Health and Human Services for the Office of Inspector General. “The flow of Medicare money has been shut off to this husband and wife team.”

"Today's verdict validates the FBI's commitment to investigate those who take advantage of our health care system and defraud the American public," said A. Todd McCall, the special agent in charge of the FBI's Memphis division. 

"We will continue to work tirelessly with our law enforcement partners and the U.S. Attorney's Office to investigate and prosecute those who commit health care fraud."

The Medlocks face up to 20 years in prison, plus an additional mandatory two years, for aggravated identity theft and a $250,000 fine.

Any sentence following conviction will be imposed by the court after consideration of the U.S. sentencing guidelines and applicable federal statutes.

Federal Medicare Fraud Strike Force Charges Chicago-Area Defendants with Defrauding Medicare and Other Health Insurers

U.S. Attorney’s OfficeMay 14, 2013

Northern District of Illinois(312) 353-5300

CHICAGO—Two area physicians and three health clinic co-owners are among seven defendants charged here with engaging in five separate, unrelated health care fraud schemes to defraud the Medicare program and/or private health insurers of millions of dollars, federal law enforcement officials announced today.

Four of the five cases here are part of a nationwide takedown by Medicare Fraud Strike Force operations in eight cities, announced today by the Departments of Justice and Health and Human Services, resulting in charges against 89 defendants, including doctors, nurses, and other licensed medical professionals, for their alleged participation in Medicare fraud schemes collectively involving approximately $233 million in false billing.

In Chicago, the defendants were charged in two criminal complaints and two informations filed today and yesterday, and an indictment that was unsealed today following the arrest of one defendant in Miami. All seven defendants were charged with health care fraud for allegedly defrauding the Medicare program, or violating the anti-kickback statute, which makes it illegal to offer, pay, solicit, or receive payments in exchange for referrals of Medicare patients. The charges involve various medical treatments and services, as well as durable medical equipment.

“Today’s announcement marks the latest step forward in our comprehensive efforts to combat fraud and abuse in our health-care systems,” said Attorney General Eric Holder. “These significant actions build on the remarkable progress that the HEAT has enabled us to make—alongside key federal, state, and local partners—in identifying and shutting down fraud schemes. They are helping to deter would-be criminals from engaging in fraudulent activities in the first place. And they underscore our ongoing commitment to protecting the American people from all forms of health-care fraud, safeguarding taxpayer resources, and ensuring the integrity of essential health care programs,” he added.

“Today’s charges are part of our continuing efforts not only to deprive dishonest healthcare providers of their illegal profits but to demonstrate to the broader medical services community that health care fraud will be found out and prosecuted with all of our resources. In short, we will not tolerate medical professionals and providers who abuse our healthcare system,” said Gary S. Shapiro, United States Attorney for the Northern District of Illinois.

Details of the Chicago cases follow:

United States v. Ankur Roy, Akash Patel, and Dipen Desai

Ankur Roy, Akash Patel, and Dipen Desai, who owned and operated Selectcare Health Inc., which provided outpatient physical and respiratory therapy in Park Ridge and Skokie, were charged with submitting more than $4 million in false billings to Medicare between March and July 2011. Each defendant was charged with six counts of health care fraud in an indictment that was returned by a federal grand jury last Wednesday and unsealed today.

Roy, 36, of Miami was arrested today in south Florida, while Patel, 33, of Morton Grove, and Desai, 33, of Chicago, will be ordered to appear for arraignment on a later date in U.S. District Court in Chicago.

According to the indictment, the defendants submitted false claims to Medicare and Blue Cross Blue Shield on behalf of Selectcare patients for respiratory therapy services that were never provided. The alleged false billings sought reimbursement for services purportedly provided on days that Selectcare’s sole respiratory therapist was not working; for time periods in which the patients were not receiving care from Selectcare; and for treatment seven days a week for three hours per day, a schedule well in excess of any schedule prescribed for patients at Selectcare.

Roy, Patel, and Desai used a third-party billing service to forward the alleged false claims to Medicare, as well as to private insurers such as Blue Cross if the patient had supplemental private insurance, including insurance funded by labor union health and welfare plans.

Between March and July 2011, the defendants allegedly submitted $4,009,094 in false billings for services that were purportedly provided between April 2010 and April 2011, resulting in payments totaling approximately $2,214,424 from Medicare and $320,881 from Blue Cross Blue Shield. The indictment seeks forfeiture of $2,535,305 in alleged fraud proceeds, including $446,974 in funds withdrawn by cashiers’ checks that were seized by the FBI in July 2012.

The government is represented by Assistant U.S. Attorney Maureen Merin. The case was investigated by the FBI, the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), and the U.S. Department of Labor Office of Inspector General (DOL-OIG).

United States v. Cecilia Ibrahim

Dr. Cecilia Ibrahim, an internal medicine physician who operated Sunrise Medical Center in Flossmoor, was charged with one count of health care fraud for allegedly engaging in a $1.7 million Medicare and private insurance false billing scheme.

Ibrahim, 50, of Frankfort, was charged in an information filed today in U.S. District Court. She will be arraigned on a date to be determined.

Between March 2006 and August 2009, Ibrahim allegedly submitted more than 3,200 false claims to Medicare and Blue Cross Blue Shield using a billing code for spinal decompression neuroplasty, a surgical procedure that she did not perform, when she only performed intervertebral differential dynamics therapy (IDD), a non-surgical procedure. As a result, she allegedly caused a loss of at least $300,000 to Medicare and $550,000 to Blue Cross Blue Shield. The indictment seeks forfeiture of at least $882,500 in alleged fraud proceeds.

The government is represented by Assistant U.S. Attorney Samuel B. Cole. The case was investigated by the FBI, HHS-OIG, and the Railroad Retirement Board Office of Inspector General.

United States v. Ellyse Lamon

Elysse Lamon, an account executive at a company that sold durable medical equipment, including back braces and transcutaneous electrical nerve stimulation units, also known as tens units, was charged with one count of health care fraud for allegedly engaging in a $350,000 Medicare false billing scheme.

Lamon, 30, of Elmhurst, was charged in an information filed today in U.S. District Court. She will be arraigned on a date to be determined.

Between October 2010 and May 2011, Lamon allegedly caused her company to submit false claims to Medicare representing that a physician had prescribed back braces and tens units when she knew that no physician had done so and the items were not medically necessary. In order to provide written support for the false claims, Lamon allegedly obtained patient records without a physician’s permission and added false information reflecting that a physician had ordered the equipment for the patients. She allegedly forged doctors’ signatures on documents, including false treatment records she created. Lamon further used patient information she had inappropriately accessed at a pain medicine center in Chicago to set up patient meetings where she falsely told patients that doctors had prescribed the equipment for them, according to the charges.

Lamon allegedly submitted false claims to Medicare totaling $352,685, resulting in payment of at least $206,233 to her medical equipment company. She allegedly profited from these false claims by receiving increased commissions and other benefits from her company.

The government is represented by Assistant U.S. Attorney Kruti Trivedi. The case was investigated by the FBI and is not part of the Medicare Fraud Strike Force operation.

United States v. Nalini Ahluwalia

Dr. Nalini Ahluwalia was charged with one count of violating the anti-kickback law for allegedly receiving $1,000 in exchange for referring two patients to a home health care agency in August 2012.

Ahluwalia, 58, of Burr Ridge, was charged in a complaint filed today in U.S. District Court. She will be ordered to appear on a date to be determined.

According to the complaint, a confidential informant who worked at a home health care company in Chicago, told agents that the confidential informant had previously paid kickbacks to Ahluwalia of $400 to $500 per patient in exchange for her referral of Medicare patients to the home health care company.

On August 23, 2012, at the direction of agents, the confidential informant met with Ahluwalia at the doctor’s office in Chicago and paid her $1,000 for the two Medicare patient referrals in an exchange that was reflected on an audio/video recording, according to the complaint affidavit. In October 2012 and February 2013, the informant allegedly made two additional $500 payments to Ahluwalia in exchange for Medicare patient referrals.

The government is represented by Assistant U.S. Attorney Samuel B. Cole. The case was investigated by the FBI and the HHS-OIG.

United States v. Joseph Dickson

Joseph Dickson, the president and owner of JD Medical Consultants Inc., a medical marketing company, was charged with one count of violating the anti-kickback law for allegedly receiving $4,200 in exchange for referring patients to a home health care agency in October 2012.

Dickson, 65, of Lansing, was charged in a complaint filed yesterday in U.S. District Court. He will be ordered to appear on a date to be determined.

According to the complaint, a confidential informant who owned a home health care company in the Chicago area, told agents that the confidential informant had previously paid kickbacks to Dickson, among others, for referring Medicare patients to another home health care company where s/he previously worked. Dickson was described as a “middle man” who arranged the referral of patients from a physician to a home health care company, and the confidential informant told agents that the confidential informant had paid Dickson approximately $15,000 for referring about 30 patients between 2006 and 2008.

On October 3, 2012, at the direction of agents, the confidential informant met with Dickson at his office in Chicago and paid him $4,200 for seven Medicare patient referrals, at $600 each, in an exchange that was reflected on an audio/video recording, according to the complaint affidavit. In December 2012, the informant allegedly made an additional $1,800 payment to Dickson in exchange for Medicare patient referrals and re-certifications.

The government is represented by Assistant U.S. Attorney Joseph H. Thompson. The case was investigated by the FBI and the HHS-OIG.

The charges in these cases carry the following maximum penalties on each count: health care fraud—10 years in prison and a $250,000 fine, or an alternate fine totaling twice the loss or twice the gain, whichever is greater; and violating the anti-kickback statute—five years in prison and a $250,000 fine. If convicted, the court must impose a reasonable sentence under federal statutes and the advisory United States Sentencing Guidelines.

The Medicare Fraud Strike Force began operating in Chicago in February 2011 and consists of agents from the FBI and HHS-OIG working together with prosecutors from the U.S. Attorney’s Office and the Justice Department’s Fraud Section. The strike force is 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 HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Since their inception in March 2007, strike force operations in nine locations have charged more than 1,500 defendants who collectively have falsely billed the Medicare program for more than $5 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The nationwide takedown was announced today by Attorney General Holder, HHS Secretary Kathleen Sebelius and other federal law enforcement officials. Mr. Shapiro announced the Chicago charges with Cory B. Nelson, Special Agent in Charge of the Chicago Office of the Federal Bureau of Investigation; Lamont Pugh, III, Special Agent in Charge of the Chicago Regional Office of the HHS-OIG; and James Vanderberg, Special Agent in Charge of the Labor Department Office of Inspector General in Chicago. The Railroad Retirement Board Office of Inspector General assisted in the Ibrahim investigation.

The public is reminded that indictments, informations, and complaints contain only charges and are not evidence of guilt. The defendants are presumed innocent and are entitled to a fair trial at which the government has the burden of proving guilt beyond a reasonable doubt.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to www.stopmedicarefraud.gov.

U.S. Renal Care to Pay $7.3 Million to Resolve False Claims Act Allegations

Department of Justice

Office of Public Affairs

FOR IMMEDIATE RELEASE

Tuesday, May 21, 2013

U.S. Renal Care to Pay $7.3 Million to Resolve False Claims Act Allegations

Allegedly Submitted False Medicare Claims for Drug Provided to Dialysis Patients

U.S. Renal Care, headquartered in Plano, Texas, has agreed to pay $7.3 million to resolve allegations that Dialysis Corporation of America (DCA) violated the False Claims Act by submitting false claims to the Medicare program for more Epogen than was actually administered to dialysis patients at DCA facilities, the Justice Department announced today.  U.S. Renal Care, which acquired DCA in June 2010, owns and operates more than 100 freestanding outpatient dialysis facilities throughout the United States.
Epogen is an intravenous medication that is used to treat anemia, a common condition afflicting patients with end-stage renal disease.  Epogen vials contain a small amount of medication in excess of the labeled amount, known as “overfill,” to compensate for medication that may remain in the vial after extraction and in the syringe upon administration.  The United States contends that from January 2004 through May 2011, DCA billed for 10-11% overfill whenever it administered Epogen.  However, because of the types of syringes DCA used, the United States alleges that DCA was not able to withdraw and administer 10-11% overfill every time it administered Epogen to patients, and thus submitted false claims to Medicare that overstated the amount of Epogen that it was actually providing.
“Today’s settlement shows that the Justice Department will aggressively pursue those health care providers who cut corners at the expense of the American taxpayers, such as by billing for items and services that were not provided,” said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division.  “We will continue to protect scarce Medicare dollars.”
“Medical care providers who submit false claims for services and products that were not actually delivered threaten the financial viability of the Medicare Trust Fund,” said Rod J. Rosenstein, U.S. Attorney for the District of Maryland.
“Health providers billing for phantom services cheat taxpayers, cheat programs straining to pay for vitally needed care, and cheat patients who pay inflated copayments,” said Nick DiGiulio, Special Agent in Charge, Office of Inspector General, U.S. Department of Health and Human Services for the region including Maryland.  “We will continue to work with the Department of Justice to ensure health professionals get reimbursed only for services they actually provide”
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 by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover $10.2 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $14.2 billion.
The allegations settled today arose from a lawsuit filed by Laura Davis against DCA under the qui tam, or whistleblower, provisions of the False Claims Act. The Act allows private citizens with knowledge of fraud to bring civil actions on behalf of the United States and share in any recovery.  Ms. Davis will receive $1,314,000 as part of today’s settlement.
This case was handled by the Civil Division of the Department of Justice and the U.S. Attorney’s Office for the District of Maryland with assistance from the Office of Inspector General for the Department of Health and Human Services.  The claims settled by this agreement are allegations only, and there has been no determination of liability.  The whistleblower suit is captioned United States ex rel. Laura Davis v. Dialysis Corporation of America, No. 1:08-cv-2829 (D. Md.).