Do your Patients Have the Knowledge to Make Good Food Choices?

Carbohydrates are your body's primary energy source! They should never be avoided, but it is important to understand that not all carbs are created equal!

Good Carb Bad Carb Trivia

Carbohydrates are an important part of a healthy diet, but there's much discussion about the good and bad carbs. So how do you know which is which? The answer is both simple and complex!

Click the picture above to launch the game!

Visit www.mhealthgames.com for more games.

CMS Issues New Telemedicine Guidelines and Approves Seven New Procedures in Move to Further Encourage Telehealth Initiatives

As the Medicare program expands telemedicine services, the opportunity may arise for sub-specialist pathologists to offer consultation services across state lines

More use of telemedicine across state borders has long been predicted as a way to improve access to care—particularly for patients in rural areas—as well as to give physicians and patients access to talented sub-specialists. Within the anatomic pathology profession, however, there are probably as many pathologists who view telemedicine across states lines to be a threat as there are pathologists who see it as an opportunity to raise the quality of care.

For its part, the Centers for Medicaid and Medicare Services (CMS) is taking a step forward in supporting the wider use of telemedicine. It is issuing new rules that expand reimbursement for remote patient services, a move that one day could benefit pathologists who provide sub-specialty pathology consultations with referring physicians across state lines.

CMS Added Seven Procedures to Its New Telehealth List

When final payment rules governing how Medicare will pay healthcare providers and suppliers in 2015 were released last October, CMS added seven procedures to the telehealth list of covered services, including annual wellness visits, psychotherapy services, and prolonged services in the office.

The American Telemedicine Association (ATA), which has long advocated for widespread use of telemedicine, praised the CMS for opening the door to greater access to telemedicine.

“It’s been a long time coming, but this ruling making signals a clear and bold step in the right direction for Medicare,” Jonathan Linkous, CEO of ATA, said in a statement. “This allows providers to use telemedicine technology to improve the cost and quality of healthcare delivery.”

What This Means for Pathologists

As the use of telemedicine becomes more common, states will be pressured to revise physician licensure laws to make it easier for out-of-state physicians to provide telemedicine services to in-state patients. For the medical laboratory profession, this might eventually make it possible for pathologists to one day be able to remotely monitor chronic patients using patient self-test devices that upload lab test results in real-time to their clinical laboratories.

For now, remote patient monitoring will continue to be available only to some Medicare patients. As Politico points out, CMS stopped short of dropping the provision requiring patients to be in a rural location to receive billable telemedicine services.

“We do not have authority to implement many of these revisions under the current statute,” Politico quoted CMS as stating. “The CMS Innovation Center is responsible for developing and testing new payment and service delivery models to lower costs and improve quality for Medicare, Medicaid, and CHIP beneficiaries. As part of that authority, the CMS Innovation Center can consider potential new payment and service delivery models to test changes to Medicare’s telehealth payment policies.”

In all, Medicare payments to telehealth are 0.8% higher in 2015.

Chronic-care Management Receives New Code: Causes Confusion

The CMS also added a new Current Procedural Terminology (CPT) code for chronic care management services. However, this change may not be as significant as first thought, because, as the ATA explained in a statement, “CMS has once again not allowed payment for data collection.”

In an iMedicalApps.com article, Perry Payne, M.D., J.D., M.P.P., Assistant Research Professor in the Department of Health Policy at the George Washington University School of Public Health and Health Services (GW), and an adjunct at Howard Law, addressed the initial confusion over the Medicare rule allowing for payment for chronic-care management.

“Some media outlets and organizations that support telemedicine are reporting that CMS is paying for remote monitoring of chronic care management patients because of a new rule that offers providers reimbursement for non-visit based services for chronic care management patients,” Payne wrote. “However, this change is not focused on telehealth or digital health services as it can include many other activities.”

Health Plans Support Telemedicine

Greater CMS reimbursement for telemedicine likely will be the impetus needed for more private payers to jump on the telemedicine bandwagon. For now, Aetna, Highmark, and Cigna are among the private insurers reimbursing for telemedicine and telehealth services, Healthcare IT News reported.

Highmark has been an early adopter of telemedicine. The private payer first offered primary care visits through Teladoc to beneficiaries in 2012. In January 2015, Highmark became the first health insurer in the country to offer teledermatology as a covered benefit.

“We need to make sure our members get the right care in the right setting, and telemedicine is a key tool to help make that setting more patient-centered,” said Donald R. Fischer, M.D., MBA, Highmark Senior Vice President and Chief Medical Officer, in a company statement. “Telemedicine is a resource that is critical to transforming the delivery of healthcare. It ensures faster access to high-quality healthcare while also helping to control costs.”

Texas Erects Barriers to Telemedicine

Telemedicine, however, still remains controversial. In April, the Texas Medical Board voted to rein in the practice of telemedicine in Texas by requiring physicians to conduct in-person visits with patients before providing diagnoses or prescribing drugs by phone or video, the Houston Chronicle reported. The only exception would be if a patient is at a healthcare facility such as a hospital, clinic, or pharmacy, and has another healthcare professional with them. Mental health visits are excluded from the rules.

“What the board is trying to do is really to keep patients safe,” Douglas W. Curran, M.D., a family physician and Vice Chair of the Texas Medical Association Board of Trustees, told the Houston Chronicle. “They want patients to be seen and evaluated so that patients can get the very best car possible. And I happen to agree with that.”

Opportunities for Pathologists

What pathologist will want to note is that CMS is taking another forward step in supporting the expanded use of telemedicine. That will put pressure on states to revise their physician licensure laws to make it easier for out-of-state physicians to provide telemedicine services to in-state patients. As that happens, this trend may open the door for more pathologists to provide sub-specialty pathology consultations with referring physicians across state lines and do patient consults as well (that are reimbursable to the consulting pathologists).

Read more: CMS Issues New Telemedicine Guidelines and Approves Seven New Procedures in Move to Further Encourage Telehealth Initiatives | Dark Daily http://www.darkdaily.com/cms-issues-new-telemedicine-guidelines-and-approves-seven-new-procedures-in-move-to-further-encourage-telehealth-initiatives-608#ixzz3ceYthMR9

Healthcare Fraud Investigations to Target Corporations and C-Suite Executives

On Thursday, May 14, 2015, at a meeting of the American Bar Association’s Healthcare Fraud Section, Leslie Caldwell, the Assistant Attorney General for the Department of Justice (DOJ) Criminal Division, declared stamping out healthcare “fraud and holding those who commit this fraud accountable are core missions of the Criminal Division and the Justice Department.” In addition to the ongoing operations of her team of more than 40 specialized healthcare prosecutors at the DOJ, Medicare Fraud Strike Force, and local United States Attorneys’ Offices, AAG Caldwell also described a renewed and intensified focus on executives and corporations:

The Strike Force will follow evidence of healthcare fraud wherever it leads, including into corporate boardrooms and executive suites. The Criminal Division has a long record of holding executives responsible for their criminal wrongdoing in cases involving financial fraud. You should expect to see us building on that record in the field of healthcare fraud.

No stranger to corporate prosecutions, as the former director of the Enron Task Force, AAG Caldwell cited the immense resources at her disposal for combating healthcare fraud across the country. Pointing to more than a dozen active corporate healthcare fraud investigations currently under way at DOJ, she made clear that the bar should expect to see more action in this area. AAG Caldwell has reason to be optimistic about the overall success of her renewed healthcare focus, as the Strike Force has made an imposing start:

In the last fiscal year alone, the Strike Force charged 353 defendants. Of those 353 defendants charged, 304 pleaded guilty and 41 were convicted at trial. The Strike Force has an overall conviction rate of 95 percent—a spectacular rate of success considering the volume and the complexity of the prosecutions—and secures prison sentences averaging more than 50 months.

AAG Caldwell further stressed the importance of cooperation for companies that have discovered healthcare fraud, noting “put simply, companies seeking credit for cooperation must conduct a thorough internal investigation and turn over all available evidence of wrongdoing to our prosecutors in a timely and complete way.” The hallmarks of cooperation, she emphasized, were candor and completeness. According to AAG Caldwell, DOJ will expand its geographic scrutiny of potential fraud hot spots to include New York, Dallas, Houston, Detroit, Chicago, and Los Angeles, meaning more companies are going to be under increased scrutiny than ever before.

With AAG Caldwell’s remarks in mind, it is incumbent on all healthcare companies and executives to implement and enforce rigorous compliance policies and programs. In many ways the vanguard of fraud prosecutions, AAG Caldwell also stressed the importance of cybersecurity measures to prevent the fraudulent acquisition or use of patient data. This latter aspect is likely to permeate all fraud prosecutions in the future, as companies face increased pressure to protect client and customer data, but it is nowhere more scrutinized at this time than in the healthcare sector.

Read more:

http://www.bakerlaw.com/alerts/justice-to-target-corporations-and-c-suite-executives-in-the-healthcare-industry?utm_source=Mondaq&utm_medium=syndication&utm_campaign=View-Original

Educating Patients on Warfarin, One Game at a Time

​Patients receiving warfarin will often need to continue taking it after discharge from the hospital, and some may require warfarin therapy for a long time. It is important that patients receive education about the drug while they are in the hospital so they can manage their therapy properly at home. Patients who are knowledgeable about their medication therapy can help to reduce the risk of adverse drug events. Education should begin with the patient’s first dose of warfarin, and all patient education needs regular reinforcement.

Tips

·        Educate patients as well as their family members or other people who live with the patients or assist with their care.

·        Use patient-directed dosing as a way to ensure that patients understand what they are taught about managing their warfarin therapy.

·        Continue education on an outpatient basis through a clinic or dosing service.

·        Use innovative tools, such as games and apps, to reach your patients post discharge.

o   Cardiac Island, from mHealth Games reinforces important objectives for patients taking Coumadin. Click the picture below to play.

Cardiac Island

Join Captain Jack on a race for treasure around Cardiac Island! Test your knowledge of Coumadin (Warfarin) and unlock treasures of health and wellness.

Exchange enrollees study by Truven Health Analytics reveals surprises

It’s only one study based on the health data of one unnamed state. But if the results of the Truven Health Analytics study are at all typical of the general U.S. population, then insurers offering coverage through health care reform exchanges should be braced for some very high utilization numbers by an unexpectedly older consumer population.

Truven said it used the data provided by “a large health plan to investigate demographics, risk, financial factors, and utilization patterns in the exchange population of its state.” The results of the analysis suggest that some of the basic predictions about those who would purchase coverage through an exchange might have been way off. Truven did not identify either the state or the health plan.

Report findings include:

• Exchange Attracted Older Enrollees: The average enrollee age in the state that was chosen for the study was 46 for the exchange population and 44 for those off the exchanges. Only one plan – the catastrophic level – had an average age under 44 (31 years).
• More Admissions, ER Visits: Exchange enrollees had a whopping 39 percent more admissions and 64 percent more emergency department visits per 1,000 enrollees than non-exchange insureds. Medical and prescription drug utilization increased as the plan design level increased.
• Higher Rate of Chronic Conditions: Exchange enrollees had 44 percent more instances of congestive heart failure and 39 percent more diabetes cases in exchange members. Additionally, exchange enrollees experienced more seizure disorders and convulsions (26 percent), asthma (21 percent), and major depressive disorder (8 percent) versus non-exchange counterparts.
• Silver Plans Dominate Exchanges: Silver plans (including both standard silver and cost-sharing reduction plans) are the preferred plan of choice for exchange enrollees, with an 82 percent market share. Bronze enrollees accounted for just 6 percent, while platinum had 4 percent of the market.
“Now, more than ever, health plan leaders need to understand details about their unique populations to create appropriate product strategies and plan designs for the future,” said Barbara Graovac, senior vice president at Truven Health Analytics. “With this snapshot of one state’s exchange population, it becomes clear how profound the differences between an exchange and off-exchange health plan population can be, and, how different reality is from initial predictions.”

http://www.benefitspro.com/2015/05/19/exchange-enrollees-study-by-truven-health-analytic

A New Mobile Tool to Assess the Need for Independent Life Skills Training

Did You Know?

Over half a million people are homeless. On any given night, there are over 600,000 homeless people in the U.S., according to the US Department of Housing and Urban Development (HUD). Most people are spending the night either in homeless shelters or in some sort of short-term transitional housing. Slightly more than a third are living in cars or under bridges or are in some other way living unsheltered.

What Can We Do?

Today, we not only know that housing ends homelessness, we also know that not everyone will need the same assistance. Some individuals will need permanent supportive housing, but others can make the transition with far less assistance. Accurate identification of those who need a higher level of services is a constant battle for mental health professionals working on the front lines.

A Call to Action

In a recent meeting with a non-profit organization who provides services to those in crisis, we were presented with this problem: How do we move beyond the traditional check boxes when evaluating an individual’s readiness for independent living? How can my outreach team effectively evaluate life skills in the field?   

Life skills are the skills that many people take for granted, like managing money, shopping, cooking, running a home and maintaining social networks. They are essential for living independently.

The Solution

Skills for a Better Life gives organizations a standard mobile tool to assess the need for life skills training.

Click on the picture below to launch:

Do you need help with a specific problem? Contact mHealth Games today for a high value, low cost solution. 

Improving Health Literacy Among Cancer Caregivers

ASCO recently published their paper on  State of Cancer Care in America 2014. In this paper, authors outline concerns and possible courses of action. The report addresses cancer costs, increasing treatment options, growing number of cancer survivors, disparities of care and the challenges of meeting these needs and concerns.

ASCO predicts that by 2030, new cancer cases in the US will rise by 45%. By 2022, there will be almost 18 million cancer survivors, about a 35% increase from today. But ASCO is also predicting a national shortage of oncology specialists by 2025. New treatment options will increase the number of cancer survivors, which is a good thing, but the shortage of specialists will result in a strain on the existing providers and a possible decrease in quality or continuum of care for some patients. Disparities of care for certain ethnic groups coupled with rising costs of medications and treatment could further result in problems with quality or access to care. Besides shortage of oncologists and disparities of care, uneven geographic distribution of physicians leave those in rural areas wanting. ASCO cites an analysis of demographics showing that nearly 90% of oncologists practice in urban areas and that more than 70% of US counties analyzed had no medical oncologist at all.

As a direct result of the above challenges, cancer patients (and their families and caregivers) will have to take a more active role in managing their health.

What tool is your organization using to educate caregivers?

How are you measuring success with specific outcomes?

Are you looking for new and improved ways to educate caregivers?

If so, mHealth Games can help!

Click the image below to launch:

Care-G Command Center

Mission Critical Care: If someone you love has been diagnosed with cancer, you've just become a very important part of their care team. Are you ready for basic training?

82% of Patients Report Unsatisfactory Education from their Primary Care Physician

What is the health literacy of patients with chronic kidney disease?

Generally, 9 out 10 adults lack the skills necessary to prevent disease or manage their health, but what about those with a chronic disease? A recent study published in the Australian Internal Medicine Journal aimed to determine patients’ understanding of chronic kidney disease when first presenting to a kidney specialist.

Two hundred and ten newly referred patients to a nephrology clinic were surveyed with open-ended questions about their understanding of CKD causes, symptoms and management. The average age of participants was 66.5 and 50.5% were female. 82% were referred by their primary care provider and 29% had previously seen a nephrologist. The results were:

• 16% of patients were unsure why they were referred
•  40% were unsure about what causes CKD
•  51% were unsure of how to manage CKD
• 82% reported unsatisfactory education from their primary care physician.

If you are struggling with ways to engage and educate your patients – mHealth Games wants to help!

Consider Fight Back, a short game to educate patients and caregivers on the basics chronic kidney disease.

Click on the picture below to play:

Fight Back

Chronic kidney disease does not have to prevent you from being a superhero! This quick training covers the basics of kidney disease and what you can do to fight back. Are you ready to join TEAM KIDNEY?

NHS England launches library for accredited mobile health apps

 

By: Jonah Comstock | Mar 24, 2015 

The National Health Service in the UK is taking steps to create a curated database of government-approved mobile health apps, starting in the area of mental health. NHS England launched a library of five approved apps on its NHS Choices website, which gets 40 million visits per month, according to the NHS.

As a large public health system, NHS struggles with waiting lists for health services including mental health. So they’ve aggressively looked to mobile health as a way to connect people to health services more efficiently. NHS began publicly evaluating mental health apps in February 2013, when they published a discussion paper on the subjecthttp://mobihealthnews.com/20154/uk-government-weighs-digital-tools-for-mental-health/.

“We want to offer people the chance to use apps and digital tools routinely to help them take control of their own healthcare,” Tim Kelsey, the National Director for Patients and Information, said in a statement. “There are online services already working for patients and we hope, by giving them our official backing, we will give clinicians, citizens and carers the confidence to use them. Digital platforms have a key role to play in improving access to psychological therapies and helping us meet our ambition of achieving parity of esteem for mental health services.”

Right now, the site has five vetted online resources: Beating the Blues, a CBT-based computer self-help course for anxiety and depression; Big White Wall, an anonymous, curated social network for people dealing with depression; FearFighter, a CBT-based self-help course for phobias; Ieso Digital Health, which offers live CBT therapy via secure instant messaging; and SilverCloud, an online platform that offers programs for different mental health conditions. The site offers descriptions of each program, instructions for accessing them, and a link to the clinical evidence that the program works.

The plan is to add additional mental health apps over time, as well as to eventually expand into other mobile health areas. NHS chose mental health to start because of a large base of evidence that these interventions are effective, they said in a press release.

“We’ve made great strides in the past few months by investing millions in talking therapies and eating disorder services. There is £1.25 billion in this year’s budget for children’s mental health, increased investment to help support veterans and new initiatives to help people on benefits get back into work,” Deputy Prime Minister Nick Clegg said in a statement. “But I know there is much left to do, which is why innovative pilots like this are so important, helping to provide treatment and support for those experiencing mental health crises. This showcases the NHS at its best — pioneering new ways of treating and supporting some of the most vulnerable in our society, harnessing innovative technology to help build a fairer society for us all.”

Source URL: http://mobihealthnews.com/41727/englands-nhs-launches-library-for-accredited-mobile-health-apps/

Health websites too hard to understand, studies say

Prepared by medical experts, many health websites that are supposed to provide information about physical and mental problems people may be facing, have been found to be too difficult for lay people to comprehend. 

Researchers in Europe, North America and Australia have independently found that the readability of online health information is generally written above the average reading ability of adults the information is intended to help. 

Yet researchers say the internet has been shown to be an effective medium to deliver health information and boost health literacy of the wider population, including people with lower income and less education, as well as minority groups. Provided, that is, the information is actually comprehensible to its intended audience. 

Australian researchers say that with an ageing population and increasing demand for self-management of chronic diseases to minimise health costs, combined with diversified health services and treatment choices, health literacy is considered “an essential life skill” in the 21st century.

Reading ability

Based on the assessment of the reading ability of adult Americans, the US Department of Health recommended that health information should be written at or below the sixth-grade level – the level of an 11-12 year-old child with six years of US education. 

Studies in the US and Europe, however, have found that the readability of online health information is above the average reading ability of adults. One study that reviewed 352 health websites worldwide, reported the average reading grade level was 12.3.

This meant an adult would have had to complete more than 12 years of schooling to fully understand the material. The study also found that none of the websites met the recommended reading level of grade 6. 

Australian study

In the latest study, researchers at Deakin University in Melbourne found Australian websites were too difficult for the average person to read, especially those dealing with dementia and obesity – two of the conditions becoming more prevalent in Australia.

Dr Matthew Dunn and Christina Cheng, researchers with Deakin’s school of health and social development, evaluated the readability of Australian online health information to see if it matched the average reading level of Australians. 

The results of the study, published in the Australian and New Zealand Journal of Public Health, suggest that health websites are pitched above the average Australian reading level, making them an ineffective way to provide health information to the community.

“With around 16 million Australians active online and almost 80% of them seeking out health information, the internet is clearly an important way to help people understand and make decisions about their health,” Dunn said.

“But the limited availability of easy-to-read health materials suggests that many Australians are not benefiting from the convenience of the internet. The low readability also raises concern that many readers may misinterpret the information which could lead to inappropriate healthcare decisions.”

Dunn told University World News that although the results could not be transposed to online health sites in other countries, “the literature does suggest that we would expect the same results elsewhere”. 

“I don't think it's necessarily academic writing or jargon that is obscuring meaning. I think it is the case that the language we use around health and health issues can be complex,” he said. 

“We need to be mindful that a large segment of the population don't have science degrees or even did science at school. So we need to consider how we can write this information in accessible ways without losing the meaning.”

For the study, the researchers reviewed the content of 251 web pages, representing 137 websites, relating to 12 common health conditions – bowel cancer, breast cancer, prostate cancer, heart disease, anxiety, depression, diabetes, asthma, arthritis, back pain, obesity and dementia. 

To determine readability, the pages were assessed against the recommended benchmark of year 8 reading level. The results showed that only 2.4% of pages were considered ‘easy to read’ and only 0.4% were below a grade 8 school reading level.

“None of the mean grade levels of the 12 health conditions matched the grade 8 benchmark, with information on dementia and obesity found to be the most difficult to read,” Dunn said.

“That dementia and obesity information is among the most difficult to read is cause for concern. The growing prevalence of these two conditions means it is essential that easy-to-read health information is available to meet the needs of those most at risk of developing obesity or dementia.”

A lost opportunity

The researchers believe a great opportunity to provide valuable health information to Australians is being lost: “The flexible and interactive nature of the internet has provided health professionals with a tool that has great potential to increase the health literacy of the general population,” Dunn said.

“However, the opportunity to make best use of the internet for relaying health information will be lost if agencies do not assess their websites for readability and make the necessary changes so that a larger proportion of the population can understand their information.”

In their paper, the researchers say advances in communication technology have transformed the ways consumers access health information, understand their conditions and make healthcare decisions. 

“Providing health information is a fundamental task of health education and health literacy is a major outcome. It is purported that health literacy is linked to general literacy skills which involve an individual's capacity to read, write, speak and solve everyday problems,” they write. “Hence, good and comprehensible health information is an integral part of developing health literacy.”

Dunn said studies had found that 44% of Australians had low literacy skills, making it paramount that health information be presented at a readability level to accommodate the wide range of literacy skills among the general population.

“Internet users’ ability to read health information online may also be affected by their internet behaviours and vice versa. For instance, most web users spend about 10 seconds to two minutes on a web page before deciding to read on. If consumers find the health information difficult to understand, particularly in the opening paragraphs, they may abandon the web page.”

He said the limited availability of easy-to-read health materials indicated that many Australians were not benefiting from the convenience of the internet. The low readability of the information available also raised concern that many readers could misinterpret the information which could lead to “inappropriate healthcare decisions”.

http://www.universityworldnews.com/article.php?story=20150303151720394

Get your Team in the Race for Quality with the 2015 HEDIS Marathon Challenge

Keeping your medical staff up to date with changes in regulatory guidelines, payment policies and insurance protocols is essential for your clinic’s success. Is your team prepared for a winning HEDIS season?

Take the 2015 HEDIS Marathon Challenge with mHealth Games

Click the picture below to play!

You have just received your 2015 HEDIS Action List. You have 150 patients and just less than 12 months to cross the finish line. Each question answered correctly will ensure a passing score on 10 patients, but a wrong answer could jeopardize a winning season for your entire team.

Capitated Doc Is Indicted in First MA Upcoding Criminal Case in S. Fla.

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

In the first criminal case the U.S. Attorney’s Office in South Florida has brought on alleged fraud via up-coding of Medicare Advantage diagnoses, the feds this month obtained a grand-jury indictment against a Palm Beach County physician accused of causing at least $2.11 million in excessive MA payments. At the time, Isaac Kojo Anakwah Thompson, M.D., was a capitated member of Humana Inc.’s MA provider network, but he no longer is in the network, says the company, which is not accused of wrongdoing in the indictment and contends it has repaid money as part of cooperating with the feds on the case.

Thompson pleaded not guilty in U.S. District Court in West Palm Beach, Fla., on Feb. 18, and a trial was set for March 23.

On the same date as Thompson’s plea, Humana disclosed Feb. 18 that it “recently” has received a request for information from the U.S. Department of Justice’s Civil Division about how it oversees risk-adjustment data in MA, including such aspects as medical-record reviews, use of health assessments and fraud-detection efforts. The company said in its Form 10-K filing with the SEC that it is cooperating with that request as well.

The grand jury in Florida on Feb. 3 indicted Thompson on eight counts of health care fraud that it said occurred between about January 2006 and April 2010. He allegedly did this by reporting to Humana “false and fraudulent diagnoses of Medicare beneficiaries enrolled in a Humana Medicare Advantage plan, thereby increasing the capitated payments that Medicare made to Humana and that Humana in turn made to” two entities in which Thompson was a principal.

Diagnoses Submitted Were for Serious Illnesses

The indictment charges that the claimed diagnoses the beneficiaries involved “did not suffer from” included ankylosing spondylitis (a chronic inflammatory disease of the spine), sacroiliitis (an inflammation in joints in the pelvis), inflammatory polyarropathy (five or more inflamed, swollen, tender joints) and major depressive affective disorder. Humana, which paid Thompson’s medical center about 80% of the MA capitation pay it got for beneficiaries who picked one of two Thompson entities as their primary care provider, “reported the false and fraudulent diagnoses to Medicare,” the indictment says.

The document adds that Thompson “obtained control of the fraudulent proceeds” that Humana paid to the two entities and “diverted these monies for his personal use and benefit, as well as that of others.” The charges carry maximum penalties that include 10 years of imprisonment.

Robert Nicholson, a Fort Lauderdale, Fla., attorney representing Thompson, told MAN Feb. 19 that his firm had “just entered” this case and had been told by the court not to comment on it to the media.

Asked by MAN to elaborate on the company’s role in the Thompson situation and investigation, Humana spokesperson Tom Noland said only, “We are cooperating fully with the authorities. Dr. Thompson is no longer a participating physician with Humana and was never a Humana employee. Humana has reimbursed the government to ensure that both the 20% [portion of Thompson’s billed charges kept by the insurer] and the 80% [Thompson portion] were paid back in full, thus making the government whole.”

He declined to comment on why Humana’s systems themselves wouldn’t have detected such large amounts for unusual diagnoses being billed by one of its capitated network providers or to say how much money the company reimbursed the government.

Asked whether in DOJ’s view Humana did anything wrong in the Thompson situation, a spokesperson for the U.S. attorney’s offices in south Florida told MAN, “Since this matter is ongoing, we will decline the opportunity to comment.” She also wouldn’t discuss the Humana filing.

http://aishealth.com/archive/nman022615-05

Diagnoses from 2/3/15 indictment:

..., ::::: :::: 0 u	Date	Entity	i'.:' «"J" :1:1:::    ..., <l)   .... i:o  ..::	HICN (last 5 d igits)	Fraudulent Diagnosis
1	2/8/ 2010	IM Med ical	M H	9471A	Inflammatory polyarthropathy
2	2/ 16/ 2010	IKAT	BB	2528A	Ankylosing spondylitis
3	2/ 16/ 2010	IKAT	ECi	5014A	Ankylosing spondylitis
4	2/ 16/2010	IKAT	RH	3396A	Ankylosing spondylitis
5	2/ 16/ 2010	IKAT	cs	4705A	Ankylosing spondylitis
6	4/ 5/2010	IM Med ical	RI	5697A	Major depressive affective disorder
7	4/9/2010	IM Med ical	TV	4666M	Major depressive affective disorder