The Strike Force Approach to Combatting Health Care Fraud

Bridget M. Rohde02/10/2014

The U.S. Department of Justice (DOJ), Health and Human Services Office of Inspector General (HHS-OIG) and other federal and state agencies are aggressively prosecuting health care fraud and related offenses through a strike force approach that has its roots in DOJ's historic efforts to combat traditional organized crime (or "La Cosa Nostra"). As DOJ has advised in recent press releases, this approach has been highly impactful in the health care space:

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who collectively have billed the Medicare program for more than $5.5 billion. In addition, HHS's Center for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers. 1

Below, we look at the historic organized crime strike force program, the evolution of the Medicare Fraud Strike Force (MFSF) and MFSF's current approach and seemingly ever-increasing productivity.

Historic Organized Crime Strike Forces

In the 1960s, to address the long-ignored presence of organized crime and its numerous rackets, DOJ developed an organized crime strike force program in which teams of prosecutors in cities across the country focused on the families of La Cosa Nostra operating in their local geographic jurisdictions. These prosecutors worked in partnership with investigators from a variety of federal agencies, and, sometimes local law enforcement as well. Investigations were long-term efforts, as the teams of prosecutors and agents gathered intelligence through confidential sources, electronic surveillance and other investigative techniques,and methodically built broad, deep and impactful cases.

Early on, DOJ touted the success of its organized crime strike forces in much the same way as it now does the success of MFSF: "Individuals indicted during 1968 as a result of strike force strategy numbered 71 in Brooklyn, 67 in Detroit, 34 in Buffalo, 12 in Chicago and 5 in Philadelphia." 2

At the time of the merger of the strike forces with local U.S. Attorneys Offices in 1990, there were 14 strike forces across the country, located in Brooklyn, Buffalo, Chicago, Cleveland, Detroit, Kansas City, Las Vegas, Los Angeles, Miami, New Orleans and San Francisco. 3

The success of the organized crime strike force approach (and continuing efforts of the U.S. Attorneys' Offices) was incontrovertible. Waves of prosecutions relentlessly taking down the successive hierarchies of the five New York City-based families of La Cosa Nostra is one of the more memorable local examples. While perhaps surprising at first blush, the use of a variation on this approach to combat white-collar crime, including health care fraud, now seems a logical, even inevitable, law enforcement strategy.

The Birth and Evolution of the MFSM

MFSF was initiated in March 2007, in what came to be Phase One, in the Southern District of Florida (Miami). A year later, in March 2008, Phase Two was kicked off in the Central District of California (Los Angeles). As part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, a joint effort by DOJ and HHS, in 2009, MFSF expanded to Detroit, Houston, Brooklyn, Tampa and Baton Rouge. In 2011, the program expanded to the total of nine cities it is today, by adding Dallas and Chicago.

Phase One of MFSF was announced in connection with a May 2007 takedown in the Southern District in Florida involving the indictment of organizations and individuals in connection with allegedly conspiring to defraud the Medicare program, making false claims and violating the anti-kickback statute. Thirty-eight individuals were arrested. Collectively, approximately $142 million was allegedly billed in Medicare. MFSF was then described as "a multi-agency team of federal, state and local investigators designed specifically to combat Medicare fraud through the use of real-time analysis of Medicare billing data," focusing on schemes involving infusion therapy and durable medical equipment (DMEs). 4

MFSF became much more. There was the noted expansion to nine cities. In addition to takedowns of discreet cases in particular cities, in late 2009, MFSF began conducting periodic nationwide takedowns, with individuals being arrested in a number of cities simultaneously in connection with healthcare-related offenses. A July 2010 nationwide takedown appears to be the largest such takedown to date, with the arrest of 94 individuals across the country for allegedly participating in schemes to submit approximately $251 million in Medicare claims. 5

Over the years that MFSF has been in existence, it has utilized other hallmarks of the strike force approach to fighting organized crime besides multi-agency cooperation and sprawling takedowns, including employing electronic surveillance techniques, expanding the range of crimes charged, obtaining (and issuing press releases regarding) long prison sentences imposed on individuals, and even having "most wanted" healthcare fugitives. Penalties of fines, forfeiture and restitution have been utilized to recoup public monies and disincentivize fraudsters.

The Current Look of MFSF Cases

A review of MFSF prosecutions in 2013 provides numerous insights into the increasingly broad scope and continuing effectiveness of the strike force approach to combatting healthcare fraud:

Many Venues of Prosecution. DOJ and its partners brought cases across the country, including in California, Florida, Illinois, Louisiana, Michigan, New York, Pennsylvania, Texas and Utah. Certain federal districts had a particularly high concentration of MFSF cases, including the Southern District of Florida, Eastern District of Michigan and Central District of California.

Variety of Health Care Providers Targeted. Cases targeted executives of a health maintenance organization; the owner/operator of an oncology center; the medical director of a hospice; the owner and program coordinator of an adult day care center; owners and others associated with partial hospitalization programs (PHPs); owners and others associated with home health care agencies; owners and others associated with DMEs; owners of ambulance services; and doctors, registered nurses and other medical professionals.

Types of Crimes Charged. Charges included healthcare fraud for submitting false and fraudulent claims to Medicare, violations of the anti-kickback statute, and, in some recent cases, money laundering.

Wide-ranging penalties. Sentences included the imposition of lengthy prison terms; fines, restitution, and forfeiture; exclusions from Medicare, Medicaid and other federal and state health programs; and compliance requirements.

Some specific matters further illustrate the scope of MFSF's efforts and its results.

1. May 2013 Nationwide Takedown. As noted above, MFSF's sixth nationwide takedown took place in May 2013. DOJ and HHS announced arrests in eight cities of 89 individuals, including health care company owners, doctors, nurses and other licensed medical professionals, for allegedly participating in Medicare fraud schemes involving approximately $223 million in billings. Schemes involved billings for home health care, mental health services, psychotherapy, occupational and physical therapy, and pharmacy fraud, as well as infusion therapy and DMEs. Charges included conspiracy to commit health care fraud, violations of the anti-kickback statute and money laundering. 6

2. Multi-million Medicare Fraud Scheme involving Brooklyn Clinic. In addition to the nationwide takedown, MFSF also brought or continued to prosecute individual cases that further illustrate the strike force approach and its results. One illuminating local example is a case charging a $77 million Medicare fraud scheme involving a Brooklyn, New York clinic. The owner and employees of the clinic allegedly paid kickbacks to Medicare beneficiaries and used the beneficiaries' names to bill Medicare for services that were medically unnecessary or never provided. The kickbacks were allegedly paid so that beneficiaries would keep quiet about services that were not provided or would acquiesce to treatment that was unnecessary. A network of money launderers was allegedly used to generate the cash needed for the kickbacks. 7

As of late last year, 13 individuals had been convicted in connection with the multi-million scheme. The owner of the clinic, who pled guilty to one count of conspiracy to commit money laundering, was sentenced to 15 years in prison and ordered to pay approximately $51 million in restitution and $36 million in forfeiture. Another participant—an individual described as a "no-show" doctor who allegedly let the clinic use his Medicare billing number and rarely visited the clinic except to pick up his check—was sentenced to more than 12 years in prison, ordered to pay over $50 million in restitution and another half million in forfeiture and was excluded from Medicare, Medicaid and federal health programs; additionally, New York state revoked his medical license. An individual who "impersonated" the doctor—signing medical charts and prescriptions in the doctor's name and performing medical procedures on patients even though he was not a doctor—was sentenced to eight years in prison, as well as restitution, forfeiture and program exclusions. Among those awaiting sentencing is an individual who pled guilty to laundering the proceeds of the health care fraud through a number of shell companies and bank accounts. 8

In addition to the dollar amount of the fraud scheme,the inclusion of money laundering charges and the variety and size of penalties, this case is notable because the government utilized investigative techniques historically used to investigate organized crime and, in more recent years, investigate insider trading. Specifically, the government stated in press releases regarding this case that it employed a court-authorized audio/video device concealed in a room at the clinic where conspirators gave cash to Medicare beneficiaries. Fitting in with the organized crime analogy, the room included "a Soviet-era poster of a woman with a finger to her lips and the words 'Don't Gossip' in Russian." 9

Effect of Strike Force Approach

As indicated above, in 2009, DOJ and HHS formed the Health Care Fraud Prevention and Enforcement Action Team, or HEAT, which includes the strike force efforts but is more expansive. For one, HEAT is also responsible for many significant civil enforcement actions resulting in multi-million dollar settlements over the last few years. These civil enforcement actions are developed and prosecuted using what can fairly be referred to as a modified strike force approach. DOJ and HHS, often in conjunction with one or more federal or state partner, work cooperatively to investigate and bring expansive cases against pharmaceutical or medical device companies charging violations of the False Claims Act, Food Drug and Cosmetics Act, the anti-kickback statute or other laws and regulations. Commonly, based on a qui tam complaint, an investigation will target specified conduct like off-label marketing of pharmaceuticals or introduction of adulterated drugs into commerce, seek monetary penalties and require remediation of the violations and adherence to a compliance protocol going forward.

A case in point from 2013 involved Johnson & Johnson. On Nov. 4, 2013, DOJ announced a deal requiring Johnson & Johnson and three of its subsidiaries to pay more than $2.2 billion to resolve criminal exposure and civil liability arising from marketing prescription drugs for uses not approved as safe and effective by the Food & Drug Administration (FDA), as well as for paying kickbacks to doctors and the country's largest long-term care pharmacy provider for prescribing and promoting these drugs. 10

To address its criminal exposure, on November 7, Johnson & Johnson subsidiary Janssen Pharmaceuticals Incorporated pled guilty to a misdemeanor charge of misbranding, in violation of the FDCA, in the U.S. District Court for the Eastern District of Pennsylvania. Specifically, Janssen was alleged to have introduced the drug Risperdal into the market for unapproved uses from March 2002 through December 2003, namely treating behaviors of elderly, non-schizophrenic patients suffering from dementia, when it had been approved only for the treatment of schizophrenia; the criminal fines and forfeiture component of the criminal resolution is $400 million. 11

Civil lawsuits similarly claimed that Johnson & Johnson and Janssen promoted Risperdal to doctors and nursing homes for unapproved uses in the elderly, children and mental disabled. A complaint in the Eastern District of Pennsylvania specifically alleged that the FDA repeatedly advised Janssen that marketing Risperdal as safe and effective for the elderly would be misleading. It also alleged that Janssen downplayed health risks to the elderly posed by Risperdal and improperly promoted its use in children. Speaker fees were allegedly paid to doctors to encourage them to write prescriptions. In addition, Johnson & Johnson and Janssen allegedly engaged in off-label promotion of a newer anti-psychotic drug, Invega. 12

Johnson & Johnson and Janssen agreed to pay over $1.2 billion to resolve civil liability under the False Claims Act in relation to Risperdal and Invega. In addition, Johnson & Johnson agreed to pay another $149 million in connection with the alleged kickbacks that were allegedly paid to the large long-term care pharmacy. 13

An additional component of the resolution was a five-year Corporate Integrity Agreement, described as requiring major changes to the way Johnson & Johnson's pharmaceutical subsidiaries do business. Annual compliance certifications are required by certain management employees and board members. As the government stated,"[t]his agreement is designed to increase accountability and transparency and prevent future fraud and abuse." 14

A telling remark by U.S. Attorney General Holder Eric Holder, who delivered remarks at the press conference on this resolution, is that pharmacists, who were supposed to be "gatekeepers" providing independent review of patient medications, instead recommended the drugs for unapproved uses at the companies' request. 15

Conclusion

In 2014, MFSF is in full flower. There is every reason to expect the strike force approach to be utilized for the foreseeable future, unless and until health care fraud significantly diminishes as a public concern. The specific cases arising from MSFS' efforts in 2013 can help drive risk assessments and fine-tuning of compliance programs to avoid repeating the expensive mistakes made by some in the health care industry in the past. The resolutions of these cases serve as a reminder of the need to prioritize compliance.

Bridget M. Rohde, a member of Mintz Levin in New York, is a former chief of the Criminal Division of the U.S. Attorney's Office for the Eastern District of New York.

http://m.newyorklawjournal.com/module/alm/app/ny.do#!/article/1457727614

Optometrist sentenced to 33 months in federal prison for Medicare fraud

An Augusta-based optometrist who expanded a single office into a string of offices on both sides of the Savannah River will serve 33 months in prison for Med­icare fraud.

At the end of an all-day sentencing hearing in U.S. District Court on Thursday, Judge J. Randal Hall told Dr. Jeffrey Sponseller that what troubled him most about the hours of testimony was the defense’s apparent theme that bad employees and sloppy record-keeping were to blame.

“When it comes to health care fraud, a lot of people look at these types of cases and say, ‘Well, it’s just the government,’ ” Hall said. But it’s a crime against all taxpayers who must pay for care of the elderly and disabled covered by Medicare, Hall said.

Sponseller, 48, pleaded guilty in February to filing false claims. On Thursday, he admitted he defrauded Medicare and other government health care programs from January 2008 through 2010.

The investigation centered on Sponseller’s billing for Eye Care One services for nursing home patients in Georgia.

Because of the amount of fraud – which was the subject of Thursday’s hearing – Sponseller faced a sentencing range of 33 to 37 months in prison.

Defense attorney Pete Theo­­docion challenged the government’s calculations that Sponseller defrauded Med­i­care of more than $441,000.

The Medicare billing code Sponseller used most often was for the most comprehensive exam possible that would be needed for a new and medically complex case, according to testimony from Jean Stone, the director of the Northeast Integrity Field Operations of the Centers for Medicare and Medicaid Services.

When Stone studied case files collected from Spon­sel­ler’s office and nursing homes, the documentation was completely inadequate for such billing. In fact, it was so minimal that it wouldn’t qualify for any kind of Medi­care payment, she said.

Kim Reinken, an investigator with the U.S. attorney’s office, analyzed Sponseller’s billings and case files, finding that on a single day in July 2009, he billed Medicare for the 45-minute comprehensive exam on 177 patients.

She also found that Sponseller was the highest recipient of Medicare payments for that billing procedure in the nation. The second-highest recipient billed for less than half of what Sponseller did.

FBI Special Agent Paul Ku­bala testified that at one nursing home, Sponseller billed for comprehensive exams of 59 patients in about three hours. Four of those patients told the nursing home director that they never saw Sponseller, and another patient didn’t have eyes.

An investigator with the Of­fice of Inspector General of Health and Human Services, David Graupner, testified that in 2007, Sponseller was audited and placed in specialized tutoring for Medi­care billing because of questionable billing practices.

In 2009 and 2010, one of the billing codes Sponseller used was for a specialized photograph. No such photographs were found in any of his patient records, Graupner testified.

Assistant U.S. Attorney David Stewart argued that the nearly half-million dollars in restitution was a reasonable request. The government wasn’t seeking repayment of more than $1 million paid to Sponseller over the two-year period in question.

In the end, the judge sided with the prosecution. A telling factor for Hall was that while Sponseller was billing for a procedure required for a difficult diagnosis or a very ill patient, rarely did he seek payment for follow-up treatment of these patients.

http://m.chronicle.augusta.com/news/crime-courts/2014-01-09/optometrist-sentenced-33-months-federal-prison-medicare-fraud

Speech therapist stole thousands from Medicaid, authorities say

A licensed speech therapist from Orange County was arrested Friday after she was accused of committing Medicaid fraud and stealing several thousand dollars.

Tiffany Campbell filed false records so she could collect payment for services she never completed last summer, a statement from the Attorney General Pam Bondi's office said.

"Campbell's employer billed Medicaid for more than $8,000 in speech therapy services never rendered based on Campbell's fraudulent logs," the statement said.

Campbell was supposed to be helping young children between 3 and 13 years old. But according the parents of Campbell's patients, the speech therapist regularly canceled appointments and refused to work over the summer.

If convicted, Campbell could face up to five years in prison or up to $10,000 in fines.

http://touch.orlandosentinel.com/#section/-1/article/p2p-79213285/

Hospital administrator and businessmen sentenced to prison for submitting fraudulent cost reports to Medicare

MONROE, La. (AP) — A former Madison Parish Hospital administrator and two of its vendors have been sentenced for health care fraud.

U.S. Attorney Stephanie A. Finley said Tuesday that U.S. District Judge Robert G. James sentenced Charles W. Alford, 71, of Newellton, to 37 months in prison and ordered him to pay $1.3 million in restitution.

James also sentenced Barney W.I. Hughes IV, 45, of Keller, Texas, to a year in prison and ordered him to pay $566,874 restitution and Henry R. Ham, 65, of West Monroe, to 14 months in prison and $817,000 in restitution.

According to evidence presented at Monday's guilty plea, Alford was hospital administrator for Madison Parish Hospital in Tallulah; Hughes served as owner of Tech Solutions of Keller, Texas; and Ham, was owner of Insurance World in Monroe.

Both Hughes and Ham paid Alford a combined total of more than $1.3 million in kickbacks for his approval and continuation of their business agreements.

Madison Parish Hospital leased equipment and personnel from Tech Solutions to operate the hospital's nuclear medicine and ultrasound departments.

At no time did Alford or Hughes disclose to the hospital's board or Medicare that they had an exclusive agreement. From October 2006 to June 2012, the hospital paid Hughes' company $2,029,504, and Hughes paid Alford $566,874 of that total. They submitted fraudulent cost reports to Medicare at least six times from December 2006 to 2011.

Madison Parish Hospital purchased a majority of its health insurance and life insurance products from Ham. Alford and Ham negotiated and set the insurance policy rates and Alford approved Ham's billings as well as the hospital's payments to Ham.

From 2007 through April 2012, the hospital paid Ham $4,979,487, and Ham paid Alford $817,000 of that total. They submitted fraudulent cost reports to Medicare at least five times from December 2007 to 2011.

http://www.khou.com/news/national/243660141.html

Husband, wife and business associate charged with health care fraud

William Owuama, 55, Marla Owuama, 46, and Florida Holiday Island, 64, all of Houston, have been charged in an eight-count indictment alleging conspiracy to commit health care fraud, health care fraud and conspiracy to violate the federal anti-kickback statute, announced United States Attorney Kenneth Magidson.

The sealed indictment, returned Jan. 22, was unsealed this afternoon as all three defendants made their initial appearance before U.S. Magistrate Judge Frances Stacy at 2 p.m. At the hearing, Judge Stacy permitted Marla Owuama and Island be released upon posting bond. Upon surrendering his passport, William Owuama is also expected to be released upon posting bond.

The indictment alleges William Owuama was the owner of Wilmar Healthcare Systems, his wife Marla was a registered nurse and Island transported patients to and from the clinic. According to allegations, they not only paid patients for visiting the clinic in violation of the anti-kickback statute, but billed Medicare and Medicaid for vestibular testing that was never performed. The indictment also alleges the clinic billed Medicare and Medicaid under the provider number of a local doctor while that doctor was incarcerated on unrelated charges. From January 2006 through October 2009, Medicare and Medicaid paid Wilmar more than $4 million based on the alleged fraudulent claims.

If convicted, all three defendants face up to five years in federal prison and a $250,000 fine for conspiring to commit healthcare fraud and violating the anti-kickback statute. The Owuamas also face up to 10 years in prison and a $250,000 fine for the substantive healthcare fraud charges.

The investigation leading to the charges in this case was conducted by the U.S. Department of Health and Human Services – Office of Inspector General and the Texas Attorney General’s Office Medicaid Fraud Control Unit. Special Assistant United States Attorney (SAUSA) Adrienne Frazior and AUSAs Andrew Leuchtmann and John Pearson are prosecuting the case.

http://www.yourhoustonnews.com/memorial/news/husband-wife-and-business-associate-charged-with-health-care-fraud/article_13e3906b-a9f5-5b62-973f-9b3c3b2b3f2a.html?mode=jqm

USDA awards millions for telemedicine

Posted on Feb 05, 2014

By Bernie Monegain, Editor

Ozarks Medical Center in Missouri and Flagstaff Medical Center in Arizona are just two hospitals in 25 states across the country that will receive federal funding for telemedicine projects. Agriculture Secretary Tom Vilsack announced nearly $16 million in USDA grants would be disbursed for distant learning and telemedicine services.
The USDA's Distance Learning and Telemedicine Loan and Grant program provides funding to rural hospitals, clinics, schools and libraries for equipment and technical assistance for telemedicine and distance learning. Grant recipients must demonstrate that they serve rural America, prove there is an economic need and provide at least 15 percent in matching funds.


Since 2009, USDA has invested almost $150 million in the Distance Learning and Telemedicine program. The investments complement other USDA efforts to improve rural communications. In FY 2013, USDA provided $305 million in loans for broadband infrastructure. These loans will result in new or upgraded broadband service for about 120,000 rural households, businesses and community institutions once the projects are completed.



Hospitals receiving telemedicine grants are:

Alaska
Chugachmiut: $180,656
Funds will be used to re-establish a telemedicine network between Native village sites in the Chugach region and offices in Seward and Anchorage. Clinics in the villages of Tatitlek, Chenega, Port Graham and Nanwalek will be linked with Anchorage and the North Star Clinic.

Alaska Native Tribal Health Consortium: $114,842
Funds will be used to purchase video teleconferencing equipment systems for virtual sessions between patients and health care providers. It is projected that nearly 3,200 people will benefit in the first year alone. The Alaska Native Tribal Health Consortium includes nine organizations that deliver innovative telehealth solutions throughout the  Alaska Federal Health Care system.

Arizona
Flagstaff Medical  Center: $129,412
Funds will be used to purchase digital electronics and software for a telemedicine system linking the Flagstaff medical center with clinics in Coconino, Apache, Mohave and Navajo Counties. This system will connect local caregivers and their patients with specialists at Flagstaff.

Kentucky
Norton Healthcare Foundation: $259,607
Funds will be used to expand the Norton Rural Medicine Initiative. The equipment will allow Norton physicians and other medical specialists in Louisville to consult medical staff and their patients at Breckinridge Health and Westlake Regional Hospitals in Kentucky; and Scott Memorial Hospital in Indiana. With the telemedicine network, patients no longer will have to travel for pulmonary, cardiology, neurology, infectious disease and critical care.

Maine
Community Health & Counseling Services: $103,235
Funds will be used to purchase in-home patient monitors, medication dispensers and screening monitors for Community Health and Counseling Services, which serves patients in Piscataquis and Washington counties with congestive heart failure, medication compliance issues, patients who need speech pathology to address swallowing disorders. The project is expected to reduce preventable hospital visits and emergency room visits, saving time and money.

Missouri
Ozarks Medical Center: $274,638
Funds will be used to buy equipment to expand medical services to Ozarks Medical Center's four hospitals and nine clinics. Services will include tele-stroke, tele-psychiatry, tele-speech therapy and tele-dermatology.

Harrison County Community Hospital District: $500,000
Funds will be used to purchase software and equipment for Harrison County’s teleradiology system. A Radiology Information System will be purchased to connect end-user workstations at clinics in Princeton, Cainsville and Bethany. The project will also fund a new telemedicine unit for the hospital's outpatient clinic. The hospital will be able to improve operations in several departments, including emergency, respiratory therapy
and cardiac rehabilitation.

Mercy Health: $382,748
Funds will be used to purchase equipment and devices for exam rooms in 11 sites in Missouri, Arkansas and Oklahoma. Physicians and other medical specialists at Mercy Hospital in St. Louis will use the audio/video equipment for face-to-face consultations, observation and diagnosis, and treatment planning.

Mississippi
University of Mississippi Medical Center: $378,360
Funds will help a consortium of rural hospitals in Mississippi acquire high-definition video teleconferencing units for their emergency rooms, and mobile units for ambulatory care at each hospital. The University of Mississippi Medical Center will make specialists and medical personnel available through the video network to respond interactively to live emergencies from any of the participating sites.

North Carolina
Grandfather Home for Children: $393,368
Funds will be used to install video teleconferencing equipment. Grandfather Home is a facility in Banner Elk, N.C., for abused and neglected children. Video conferencing will provide critical therapeutic services for children and a direct line of communication between children and their foster parents.

New Hampshire
Mary Hitchcock Memorial Hospital: $498,356
Funds will be used to purchase equipment and software to expand the telemedicine network at the Mary Hitchcock Memorial Hospital to new sites in New Hampshire and Vermont. After this expansion is deployed, the system is projected to provide medical expertise for more than 5,000 rural residents.

Mary Hitchcock Memorial Hospital: $500,000
Funds will be used to purchase telemedical carts and related equipment for 18 rural sites. The participating sites include rural acute care hospitals, ambulatory care sites, rehabilitation sites and behavioral health centers in
Woodsville, Littleton, Greenfield, Colebrook, New London, Whitefield, Lancaster and Groveton.

South Carolina
Hampton Regional Medical Center: $249,162
Funds will be used to purchase a variety of video teleconferencing equipment and digital exam devices for the medical center and nine end-user sites. Roper St. Francis Hospital in Charleston will serve as a hub site for medical specialists and video system management. The video teleconferencing platform will allow face-to-face consultations between patients and physicians and between local health care providers and medical staff at the hub site.

Washington
Kadlec Regional Medical Center: $329,269
Funds will be used to purchase telemedicine equipment for a consortium of 12 health care organizations serving 19 sites at rural clinics along the Columbia River in Eastern Oregon and Washington. The Medical Center and participating hospitals will offer a comprehensive array of services and consultations.

West Virginia
Davis Memorial Hospital: $74,189
Funds will be used to establish telemedicine consultations between physicians at Davis Memorial Hospital and the Cortland Acres (Tucker County), Pendleton Manor (Pendleton County) and Mansfield Place (Barbour County) nursing homes. Physicians will be equipped with iPads and video-enabling software to increase their availability to observe and provide diagnosis for residents and patients.
Also USDA gave several awards that combined funding for both distance learning and telemedicine.

Missouri
Citizens Memorial Hospital District, $175,989
Funds will be used to provide telemedicine equipment for a partnership led by Citizens Memorial Hospital. The hospital and its hub partners will provide telemedicine services to rural clinics in Pleasant Hope, Rockville, El Dorado Springs, Stockton, Greenfield, Buffalo, Montrose, Wheatland, Hermitage, Humansville, Appleton City and Deepwater.

Montana
Kalispell Regional Medical Center, $363,326
Funds will be used to help Kalispell Regional Medical Center provide 24/7 telemedicine consultation services in its nine
county area. The equipment will create a telemedicine service among the Western Montana Tele-neurology Network, Kalispell Regional Medical Center and critical access hospitals in the region.

New York
Jefferson-Lewis-Hamilton-Herkimer-Oneida Board of Cooperative Educational Services, $487,267
Funds will be used to purchase video teleconferencing units for 37 schools in the Jefferson Lewis Hamilton Herkimer Oneida jurisdiction, 15 of which have never been connected to a distance learning system before. LeMoyne College in Syracuse, Clarkson University in Potsdam, Jefferson Community College in Watertown, and the Syracuse University School of Medicine will be part of the teleconference network.

Oklahoma
Board of Regents of the University of Oklahoma Health Sciences Center, $500,000
Funds will be used to purchase state-of-the-art digital equipment and software for a telemedicine initiative hosted by the University of Oklahoma Health Science Center. The initiative will use video teleconferencing to offer geriatric services to Choctaw Nation clinical sites -- including Stilwell Community Hospital -- and Choctaw clinics in Hugo, Broken Bow, Stigler, Idabel, Talihina and Atoka, and general services to health care facilities in Fort Cobb, Grandfield and Tipton.

South Carolina
South Carolina Department of Juvenile Justice, $196,809
Funds will be used to provide video teleconferencing systems for the South Carolina Department of Juvenile Justice. The equipment will give students a better chance of obtaining work skills and higher education opportunities

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Source URL: http://www.healthcareitnews.com/news/usda-awards-millions-telemedicine

Prestige Wins Florida Medicaid Contracts After the Contracted was Contested by Care Access

By CAROL GENTRY

With a billion dollars riding on the contested decision, Florida's Agency for Health Care Administration says it will award its Medicaid managed-care contract for Miami-Dade and Monroe counties to Prestige Health Choice.

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The final order, signed by AHCA Secretary Liz Dudek on Friday, rejects a recommendation from an administrative law judge who held hearings in the case in November.  The judge, John Van Laningham, wrote that the corporate structure of Prestige Health Choice did not meet the definition for a "provider service network," or PSN.

Care Access, the company that filed the protest that led to the hearings, issued a statement Monday expressing disappointment. The company plans to file an appeal with the First District Court of Appeal in Tallahassee, the statement says.

Each region of the state must offer a PSN as a choice for Medicaid enrollment, in addition to HMOs. So if Prestige was not a true PSN, then the contract would have to be awarded to a competitor. Care Access PSN, which brought the protest that led to the hearing, stood to inherit the contract if Prestige were not eligible.

Van Laningham said Prestige did not have majority ownership by doctors or other health-care providers, a requirement for designation as a PSN.   Florida True Health, a company formed by two insurers, Florida Blue and AmeriHealth Caritas, owns 40 percent of Prestige. In addition, the judge said, Florida True Health holds an option to purchase the other 60 percent of shares.

Another 13 percent of Prestige is owned by Florida Health Choice Network, which is a consortium of neighborhood health centers. Van Laningham ruled that that Florida Health Choice Network is not a Medicaid provider, so therefore Prestige could not qualify as a PSN.  His decision was issued on Jan. 2, and Health News Florida filed this report.

State agencies and boards can overrule the recommendations of hearing officers if they can cite specific errors in the legal reasoning used to arrive at a decision. They cannot override findings of fact.

In its ruling, AHCA said Van Laningham had misconstrued two sections of the law that established the statewide managed-care Medicaid program.

AHCA went ahead and signed a contract with Prestige to enroll patients in Miami-Dade, along with seven  other regions of the state (see list of plans by region). The three regions in which other PSNs were chosen were Region 2, Panhandle, Better Health Plan; Region 4, Northeast Florida,  First Coast Advantage; and Region 10, Broward County, South Florida Community Care Network.

Frank Reiner, attorney for Care Access, says the law requires AHCA to hold off on issuing the contract until the 1st District Court has ruled in the coming appeal. Health News Florida raised that question with AHCA Monday afternoon, but had not yet heard back by 6 p.m.

Miami-Dade has been hotly contested because it has the most Medicaid enrollees, and therefore the most potential new customers, for whom the state pays the premiums.  The Miami-Dade contract is expected to pay about $1 billion over five years, a Care Access spokeswoman said.

The Legislature created the law in 2011 that requires virtually all Medicaid beneficiaries -- including those in long-term care -- to enroll in a managed-care plan, either an HMO or a PSN. The Long-Term-Care rollout is under way, and the other beneficiaries will be shifted between May and August of this year.

The law does away with "fee-for-service" Medicaid payments, in which doctors, hospitals and other providers directly billed the state. Amid the gush of claims, the state found it difficult to prevent fraud and abuse. By privatizing the program -- turning management of treatment and payment over to managed-care plans -- Medicaid becomes a regulator, rather than a direct payer.

While HMOs and PSNs may seem similar from the point of view of the patient, an HMO is a commercial operation that is dually licensed by AHCA and the Office of Insurance Regulation. A PSN is a health-care network owned and run by the health-care professionals who treat the patients.

More information on the Statewide Medicaid Managed Medical Assistance Program is available here.

http://health.wusf.usf.edu/post/prestige-wins-medicaid-contracts?utm_referrer=http%3A//m.health.wusf.usf.edu/%3Futm_referrer%3D%23mobile/5383

Florida prepares to open its own health insurance exchange

Florida moves to open a state-run exchange

Florida may soon be operating its own health insurance exchange. The state has become a well known opponent of the Affordable Care Act , going so far as to seek the dismantling of the federal health care reform law through the Supreme Court as well as banning insurance navigators from working in the state. The state has missed its deadline to develop and operate a working exchange last year, meaning that a federal exchange has been set up for the state’s residents. Now, however, Florida Health Choices may soon be offering coverage.

Exchange finally shows signs of life after years of dormancy

Florida Health Choices was first established through state law in 2008. Since then, however, little has been done in regards to developing the exchange. Most of Florida’s legislative focus has been committed to opposing the health care reform law, but the state has found little success in this endeavor. State officials suggest that allowing the federal government to manage the health insurance market is dangerous and claim that the state should have more authority over the market. As such, Florida Health Choices is preparing to open itself to the public.

State-run exchange will not compete with the federal government

There is no news concerning which of the state’s insurance companies will be providing coverage through the state-run exchange. Rose Naff, CEO of Florida Health Choices, claims that the majority of Floridians are not purchasing coverage through the federal insurance exchange. Instead, these people are purchasing coverage through the private market. Naff suggests that the state-run health insurance exchange will not be competing with the federal government when it comes to selling policies.

STATE-RUN EXCHANGE EXPECTED TO BECOME OPERATIONAL IN EARLY FEBRUARY

Naff anticipates that the launch of the state-run exchange is only “a few days” away. The exchange is expected to begin operation in early to mid-February and will provide subsidies for consumers that can help them acquire the insurance coverage they need. The state-run exchange is expected to operate in a similar fashion to exchanges in other states, with Florida officials keen to ensure that the federal government has little control over the exchange itself.

http://www.liveinsurancenews.com/florida-prepares-open-health-insurance-exchange/8532045/

Innovative Pitt Competition Aims to Solve Health Problems through Patient Engagement

PITTSBURGH – In a creative, community-wide competition to spark fresh ideas that engage people in their own health care, the University of Pittsburgh is offering $300,000 in funding to three winners in its first Pitt Innovation Challenge, or PInCh.

Just as a reality TV show gives contestants an opportunity to share their inventions, PInCh will give scientists and other community members a venue to be creative and develop new ideas, said CTSI director Steven Reis, M.D., who also is associate vice chancellor for clinical research, health sciences, and a professor of medicine at the University of Pittsburgh School of Medicine. PInCh’s inaugural question is: “How do we empower individuals to take control of their own health outcomes?”

“Instead of trying to figure out the molecular mechanisms of hypertension, for example, the team might try to figure out how to reduce the rate of high blood pressure in a specific region,” Reis said. “We want to encourage researchers to approach their work in a different way. Rather than conducting experiments focused on scientific details, they must look at the big picture to try to solve a problem that has public health or clinical importance.”

According to PInCh program director John Maier, M.D., Ph.D., director of research and development and assistant professor, Department of Family Medicine, Pitt School of Medicine, the first step in the competition requires submitting a two-minute video by March 2 that introduces the team, defines the health problem that is being tackled and briefly outlines the creative solution. Early round winners will be invited to a final round of judging in May at a public event in which teams will make short presentations to a panel of judges.

“This will be a great opportunity to get new or risky ideas in front of judges who have experience in science, business, technology and other fields, so participation itself should be rewarding and fun,” Maier said. “We plan to have a ‘People’s Choice’ award, too, so everyone will have a chance to vote for projects that appeal to them.”

Anyone can enter, and teams that bring together collaborators from different perspectives, institutions and disciplines are encouraged, but at least one member of the team must be a Pitt faculty member. If needed, PInCh organizers will help community members connect with a member of the faculty. The solution could be a device, a software application, an intervention strategy or any other approach that could address the health problem the team identifies.

“We hope to de-risk wild ideas to solve clinical or public health problems by providing funding and project management to take them to the next level,” Reis said. “We think some amazing ideas will come out of this process, and we hope the PInCh model can be used in future competitions to stimulate innovative solutions to challenging issues.”

http://gantdaily.com/2014/02/03/innovative-pitt-competition-aims-to-solve-health-problems-through-patient-engagement/

A Sustainable Healthcare System Depends on Equal Access to Quality Education

“Without continual growth and progress, such words as improvement, achievement, and success have no meaning.” – Benjamin Franklin

HCMS

Health Care Management Systems was created to provide free, high quality, on-demand learning to all of those involved in the frontlines of healthcare!

Why?

Because we have proven that “equal access to high quality education” is the missing link in the healthcare equation.  Yes, proven through a unique double blind study that you have probably never heard of…

You see, this story begins about 3 years ago on the Texas gulf coast when two unlikely partners teamed up to change the way managed care was delivered to a certain Medicare population.

The strategy was devised from a simple physics theory – to influence the greatest amount of change in the shortest amount of time possible – equal pressure must be applied in all directions.

Education was the single greatest variable that was common to all groups – so our hypothesis was built on the assumption that through simultaneous and continuous education at the point of care, we could make a measurable impact on both the cost and the experience of care!

The project was a huge success from both a financial and cultural perspective. Two years later that “little experiment” is now out funding larger markers  – all without ever auditing a chart!

Lighting in a Bottle –

Okay, so our hypothesis was a success, but where do go from here? We were so amazed and excited about the outcome that we wanted to find a way to offer it to everyone – anywhere, anytime, anyplace and on any device!

So, we developed a vehicle: Global Health Care Management Systems (globalhcms.org) – an innovative learning platform that can deliver our proven education to everyone on the frontlines!

Anyone involved who wants to learn is invited to join the HCMS Academy!

To ensure that this tool will continue to be available to all of those we serve, we have teamed up with other healthcare leaders to provide employer sponsored learning as well.

A big THANK YOU to all of our partners and sponsors – without them none of this would be possible….

To learn more about our pilot program please visit: www.ermconsultinginc.com.

To find out how you can partner with us to ensure equal access to quality education email: kgifford@ermconsultinginc.com.

How Do I Sign Up?

HCMS ACADEMY-

We invite everyone currently working on the frontlines or those contemplating a new career in healthcare to register for the HCMS Academy. Register for free courses and receive certifications in Medicare Risk Adjustment, ICD-10 Coding and Rapid Practice Innovation. As a member of the Academy you are invited to join our conversation on the “Innovation X-Change.” The X-Change provides a secure, HIPPA compliant meeting space for visionaries to share ideas and collaborate on future projects. Join a group or start your own. Register today at www.globalhcms.org – What are you waiting on – it’s totally FREE!

SPONSOR E-LEARNING-

Are you involved in health care? If so, we invite you to join us in our mission! By sponsoring e-learning for your employees or industry partners you can help ensure that everyone has equal access to high quality education.

By partnering with HCMS, you extend our proven education to your organization at no cost and we are able to provide you with state of the art analytics including dashboards to track implementation and progress across large organizations in real time. This system was built on an API that accepts up to 5 data sources which potentially allows us to measure and analyze financial, educational and utilization data together for the first time. All of this at a fraction of the cost of traditional analytics.

To learn more about how we can partner for a better tomorrow, please contact: kgifford@ermconsultinginc.com

www.globalhcms.org