Cigna-HealthSpring Life & Health Insurance Company (“CIGNA”) earned poor marks for its administration of various Medicare Advantage contracts in compliance with Federal requirements in recent Department of Health & Human Services (“HHS”) Office of Inspector General (“OIG”) audits.

Audits’ Purpose

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees, who would be expected to require fewer health care resources. 

To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS. 

Separate audits of two contracts reviewed groups of high-risk diagnosis codes to determine if selected diagnosis codes that Cigna submitted to CMS for use in CMS’s risk adjustment program under the contracts complied with Federal requirements. The audits found poor compliance in both contract audits.

Contract H4513 Audit

According to an audit report made public in March, 2023, a Medicare Advantage compliance audit of the nine high-risk groups covered by the audit revealed most of the selected diagnosis codes that Cigna submitted to CMS for use in CMS’s risk adjustment program under Cigna’s Contract H4513 “did not comply with Federal requirements.”Specifically, for 200 of the 300 sampled enrollee-years, the medical records that Cigna provided did not support the diagnosis codes and resulted in $468,372 in overpayments. On the basis of the audit sample results, OIG estimated that Cigna received at least $6.24 million in overpayments for 2016 and 2017.

Based on these audit findings, OIG is recommending that Cigna:

• Refund to the Federal Government the $468,372 of overpayments;
• Identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and
• Continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements and take the necessary steps to enhance those procedures.

OIG reports Cigna disagreed with OIG’s recommendations as well as:

• OIG’s findings for 6 sampled enrollee-years which, according to Cigna, were supported by the medical records;
• OIG’s audit methodology, use of extrapolation, and standards for data accuracy, coding, and documentation requirements; but
• Cigna did not directly agree or disagree with OIG’s findings for the remaining enrollee-years.

After reviewing Cigna’s comments and the additional information Cigna provided, OIG revised the number of enrollee-years in error from 201 to 200 for this final report.

After OIG issued its draft report, CMS updated regulations for audits in its risk adjustment program to specify that extrapolated overpayments could only be recouped beginning with payment year 2018. Because the CIGNA audit period covered payment years 2016 and 2017, OIG subsequently revised its first recommendation to specify a refund of only the overpayments for the sampled enrollee-years but made no changes to its other recommendations. OIG says it followed a reasonable audit methodology and correctly applied applicable Federal requirements underlying the MA program.

OIG expressed similar findings and concerns in its audit report about an audit of the performance of Cigna-HealthSpring of Tennessee, Inc. (“Cigna-Tenn”) made public in December, 2022.

The Cigna-Tenn audit focused on 10 groups of high-risk diagnosis codes. OIG sampled 279 unique enrollee-years with the high-risk diagnosis codes for which Cigna received higher payments for 2016 through 2017. OIG limited it’s review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $759,529.

With respect to the 10 high-risk groups covered by the audit, OIG found most of the selected diagnosis codes that Cigna submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 195 of the 279 sampled enrollee-years, the medical records that Cigna provided did not support the diagnosis codes and resulted in $509,194 in overpayments.

Based on the errors found, OIG also concluded Cigna’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, needed improvement. On the basis of the sample results, we OIG estimates that Cigna received at least $5.9 million in overpayments for 2016 and 2017.

OIG recommend that Cigna:

• Refund to the Federal Government the $5.9 million of estimated overpayments;
• Iidentify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before and after our audit period and refund any resulting overpayments to the Federal Government; and
• Continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.

As with the latest audit findings, Cigna-Tenn:

• Disputed OIG’s recommendations;
• OIG’s findings for 13 sampled enrollee-years which, according to Cigna, were supported by the diagnosis codes on the medical records.
• OIG’s audit methodology, use of extrapolation, and standards for data accuracy, coding, and documentation requirements; but
• Did not directly agree or disagree with our findings for the remaining enrollee-years.

After reviewing Cigna-Tenn’s comments and the additional information provided, OIG also revised the number of enrollee-years in error from 201 to 195 for this final report and reduced the amount of the recommended repayment to $5.9 million but made no change to its other recommendations.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35+ years of workforce and other management work, public policy leadership and advocacy, coaching, teachings, scholarship and thought leadership.

A Fellow in the American College of Employee Benefit Counsel, Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Chair of the ABA Intellectual Property Section Law Practice Management Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer’s work throughout her 35 year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. As an ongoing component of this work, she regularly advises, represents and defends businesses on Guideline Program and other compliance, risk management and other internal and external controls in a wide range of areas and has published and spoken extensively on these concerns.

Ms. Stamer also is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on workforce, compensation, and other operations, risk management, compliance and regulatory and public affairs concerns.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving, and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2023 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

Physicians, hospitals, clinics and other health care providers should take any necessary steps to adjust their practices to ensure their defensibility under federal health care fraud laws when flexibilities allowed under the COVID-19 public health emergency declaration (COVID-19 Declaration) first issued on January 31, 2020  end in May, 2023 as well as audit other potential compliance risks that may have arisen from staffing or other operational disruptions that occurred during the COVID-19 pandemic.

The Secretary of Health & Human Services (“HHS”) has announced the COVID-19 Declaration will expire at the end of the day on May 11, 2023. When the COVID-19 Declaration expires, physicians and other health care providers need to recognize and begin preparing for the end of the following special flexibilities and relief that HHS granted by the HHS Office of Inspector General (“OIG”) through various Policy Statements and Frequently Asked Questions (“FAQs”) while the COVID-19 Declaration remained in effect to provide flexibility and minimize burdens for the health care industry as it faced the challenges of the COVID-19 pandemic. Other agencies that issued flexibilities or other relief during the pandemic also have or are ending that relief, The termination of these flexibilities will immediately reactivate a host of federal, state and local rules suspended softened during the COVID-19 pandemic even as the operations of agencies and the courts normalize. Amid these developments, health care providers, health care organizations and other businesses need to use care to avoid creating liability by continuing to use practices adopted under the flexibilities granted under the COVID-19 Declaration or other similar pandemic relief after that temporary relief expires.

OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19)Outbreak (“Telehealth Policy Statement”)

The Telehealth Policy Statement issued March 17, 2020 notified physicians and other practitioners that HHS would not impose administrative sanctions for reducing or waiving any cost-sharing obligations Federal health care program beneficiaries may owe for telehealth services furnished consistent with the then-applicable coverage and payment rules, as long as the provider met the conditions specified in the Telehealth Policy Statement.  The Telehealth Policy Statement imposed several conditions upon its applicability.  Since the Telehealth Policy Statement only applies while the COVID-19 Declaration remained in effect, reductions or waivers of Federal health care program enrollees’ cost-sharing obligations for telehealth services furnished after the expiration of the COVID-19 Declaration on May 11, 2023, will not receive prospective immunity from OIG administrative sanctions under the Telehealth Policy Statement.

OIG Policy Statement Regarding Application of Certain Administrative Enforcement Authorities Due to Declaration of Coronavirus Disease 2019 (COVID-19) Outbreak in the United States as a National Emergency (“OIG Blanket Waivers Policy Statement”)

The OIG Blanket Waivers Policy Statement issued April 3, 2020 announced OIG would not to impose certain administrative sanctions for certain remuneration related to COVID-19 covered by the Blanket Waivers of Section 1877(g) of the Social Security Act (Centers for Medicare & Medicaid Services (CMS) Blanket Waivers) issued by the Secretary, subject to the conditions specified in the Policy Statement. This relief will end on March 11, 2023.

The CMS Blanket Waivers applied to allow health care provider to be reimbursed for the items and services and exempted from sanctions for such noncompliance, absent the government’s determination of fraud or abuse the following referrals and claims made where necessary to ensure sufficient health care items and services remained available to meet the needs of individuals enrolled in the Medicare, Medicaid, and CHIP programs and the health care providers furnishing those items and services in good faith were unable to comply with one or more of the specified requirements of section 1877 of the Social Security Act due to the consequences of the COVID-19 pandemic:

• Remuneration from an entity to a physician (or an immediate family member of a physician) that is above or below the fair market value for services personally performed by the physician (or the immediate family member of the physician) to the entity.
• Rental charges paid by an entity to a physician (or an immediate family member of a physician) that are below fair market value for the entity’s lease of office space from the physician (or the immediate family member of the physician).
• Rental charges paid by an entity to a physician (or an immediate family member of a physician) that are below fair market value for the entity’s lease of equipment from the physician (or the immediate family member of the physician).
• Remuneration from an entity to a physician (or an immediate family member of a physician) that is below fair market value for items or services purchased by the entity from the physician (or the immediate family member of the physician).
• Rental charges paid by a physician (or an immediate family member of a physician) to an entity that are below fair market value for the physician’s (or immediate family member’s) lease of office space from the entity.
• Rental charges paid by a physician (or an immediate family member of a physician) to an entity that are below fair market value for the physician’s (or immediate family member’s) lease of equipment from the entity.
• Remuneration from a physician (or an immediate family member of a physician) to an entity that is below fair market value for the use of the entity’s premises or for items or services purchased by the physician (or the immediate family member of the physician) from the entity.
• Remuneration from a hospital to a physician in the form of medical staff incidental benefits that exceeds the limit set forth in 42 CFR 411.357(m)(5).
• Remuneration from an entity to a physician (or the immediate family member of a physician) in the form of nonmonetary compensation that exceeds the limit set forth in 42 CFR 411.357(k)(1).
• Remuneration from an entity to a physician (or the immediate family member of a physician) resulting from a loan to the physician (or the immediate family member of the physician): (1) with an interest rate below fair market value; or (2) on terms that are unavailable from a lender that is not a recipient of the physician’s referrals or business generated by the physician.
• Remuneration from a physician (or the immediate family member of a physician) to an entity resulting from a loan to the entity: (1) with an interest rate below fair market value; or (2) on terms that are unavailable from a lender that is not in a position to generate business for the physician (or the immediate family member of the physician).
• The referral by a physician owner of a hospital that temporarily expands its facility capacity above the number of operating rooms, procedure rooms, and beds for which the hospital was licensed on March 23, 2010 (or, in the case of a hospital that did not have a provider agreement in effect as of March 23, 2010, but did have a provider agreement in effect on December 31, 2010, the effective date of such provider agreement) without prior application and approval of the

Providers that have or are billing for services in reliance on the blanket waiver should keep in mind that they only apply to financial relationships and referrals that are related to the COVID-19 outbreak in the United States. Any remuneration described in the blanket waivers must be directly between the entity and: (1) the physician or the physician organization in whose shoes the physician stands under 42 CFR 411.354(c); or (2) the immediate family member of the physician.

Also, the remuneration and referrals described in the blanket waivers must be solely related to COVID-19 Purposes, which means:

• Diagnosis or medically necessary treatment of COVID-19 for any patient or individual, whether or not the patient or individual is diagnosed with a confirmed case of COVID[1]19;
• Securing the services of physicians and other health care practitioners and professionals to furnish medically necessary patient care services, including services not related to the diagnosis and treatment of COVID-19, in response to the COVID-19 outbreak in the United States;
• Ensuring the ability of health care providers to address patient and community needs due to the COVID-19 outbreak in the United States;
• Expanding the capacity of health care providers to address patient and community needs due to the COVID-19 outbreak in the United States;
• Shifting the diagnosis and care of patients to appropriate alternative settings due to the COVID-19 outbreak in the United States; or
• Addressing medical practice or business interruption due to the COVID-19 outbreak in the United States in order to maintain the availability of medical care and related services for patients and the community.

Providers must not attempt to rely upon the CMS Blanket Waivers to justify any transaction after May 11, 2023.  Furthermore, providers acting in reliance upon the CMS Blanket Waivers must not rely upon the CMS Blanket Waivers to bill for, and should take prompt action to correct billing for any services provided in reliance on the Blanket Waiver that don’t meet these or any other applicable conditions.

FAQs-Application of OIG’s Administrative Enforcement Authorities to Arrangements Directly Connected to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency

HHS beginning April 10, 2020 also published informal, nonbinding guidance in the form of Frequently Asked Questions (“FAQs”) that discussed OIG’s views on the following arrangements when directly connected to the public health emergency and implicated OIG’s administrative enforcement authorities, including the Federal anti-kickback statute and Beneficiary Inducements CMP:

• Would the offer or provision of cash, cash-equivalent, or in-kind incentives or rewards to Federal health care program beneficiaries who receive COVID-19 vaccinations during the public health emergency violate OIG’s administrative enforcement authorities?
• What are the implications, under OIG’s administrative sanction authorities, of an ambulance provider or supplier waiving or discounting beneficiary cost-sharing obligations (required by the Medicare program) resulting from ground ambulance services paid for by the Medicare program under a waiver established pursuant to section 1135(b)(9) of the Social Security Act?
• Can a federally qualified health center (FQHC) with a location in a rural area provide free space to a retail pharmacy that administers COVID-19 vaccinations to FQHC patients and the general public (including Federal health care program beneficiaries)?
• Can a non-provider philanthropic entity contract to provide certain administrative services to a health care provider relating to the operation of COVID-19 vaccination sites and be compensated on a per-vaccine basis?
• Can a Federally Qualified Health Center (FQHC), including an entity that receives grant funds or designation under section 330 of the Public Health Service Act, conduct free COVID-19 diagnostic testing that has been cleared or approved by the Food and Drug Administration (FDA), is subject to an FDA-issued Emergency Use Authorization, or is covered by the Medicare program, including for Federal health care program beneficiaries, at community health fairs and via mobile testing in underserved communities impacted by COVID-19?
• Can a provider or supplier such as a hospital, pharmacy, or health system provide other providers and suppliers with free items and services related to COVID-19 vaccine storage, distribution, redistribution, and/or administration?
• A Federally Qualified Health Center (FQHC) received from a private foundation a $15,000 COVID-19 relief grant designated for emergency cash assistance for financially needy individuals. Can the FQHC furnish cash-equivalent gift cards, in specified amounts, to address social determinants of health for financially needy individuals, including Federal health care program beneficiaries who meet certain criteria?
• Can a home health agency’s (HHA) staff members furnish free blood draws-provided that such blood draws are within the scope of the staff’s licenses-to assisted living facility residents who are Federal health care program beneficiaries and are not patients of the HHA?
• Can clinical laboratories offer free COVID-19 antibody testing to Federal health care program beneficiaries who are contemporaneously receiving other medically necessary blood tests during the COVID-19 public health emergency?
• Can an oncology practice offer free or discounted lodging to its financially needy patients who are Federal health care program beneficiaries if, prior to the COVID-19 public health emergency, such patients would have had access to free or discounted housing at a nonprofit lodging facility while receiving chemotherapy or radiation treatment?
• Can a physician group that contracts with a nursing home to provide care to its residents furnish protective face masks-at no or reduced cost-to the nursing home if it is experiencing supply shortages due to the COVID-19 outbreak?
• During the time period subject to the COVID-19 Declaration, can a clinical laboratory that bills Federal health care programs for laboratory tests to diagnose COVID-19 pay a retail pharmacy a fee for certain costs that the retail pharmacy incurs related to testing collection sites?
• Why does the “OIG Policy Statement Regarding Application of Certain Administrative Enforcement Authorities Due to Declaration of Coronavirus Disease 2019 (COVID-19) Outbreak in the United States as a National Emergency” not incorporate sections II(B)(12)-(18) of the blanket waivers of the physician self-referral law as issued by the Secretary?
• Can a hospital assist a Federally Qualified Health Center Look-Alike (FQHCLA) by suspending rental charges and forgoing the accrual of interest on a line of credit during the period subject to the COVID-19 Declaration to ensure the FQHCLA is able to continue to serve the medical needs of the community during the pandemic?
• I am an eligible provider who received a distribution through the CARES Act Provider Relief Fund. Where do I sign my attestation?
• Can mental health and substance use disorder providers accept donations from public entities (i.e., local, State, or Federal government entities), private charitable foundations, or health plans to fund cell phones, service or data plans, or both for patients who are financially needy or who do not own their own cell phone for the purpose of furnishing medically necessary services while in-person care is disrupted during the COVID-19 outbreak?
• Can an oncology group practice provide free in-kind local transportation to and from an established patient’s home to an alternate practice location to receive medically necessary oncology care during the time period subject to the COVID-19 Declaration?
• Can health care providers and practitioners furnish services, not to exceed their scope of practice, for free or at a reduced rate, to assist skilled nursing facilities (SNFs) or other long-term-care providers that are facing staffing shortages due to the COVID-19 outbreak?
• Can a hospital provide access to its existing HIPAA-compliant, web-based telehealth platform for free to independent physicians on its medical staff to furnish medically necessary telehealth services during the time period subject to the COVID-19 Declaration?

As stated in the FAQs, the informal, nonbinding feedback provided “applies only to arrangements in existence solely during the time period subject to the COVID-19 Declaration”  and that OIG may take a different position on arrangements that are the same or similar in nature that existed before the effective date of the COVID-19 Declaration or after the time such COVID-19 Declaration ends versus during the COVID-19 Emergency due to the emergency situation.  Providers also are cautioned against to seek the advice of legal counsel about the potential risks and consequences of relying on FAQ or other COVID-19 relief where their proposed activity does not obviously meet all of the assumptions and requirements stated in the applicable FAQ or other guidance. In any event, providers should not rely on any relief provided by any of the FAQs after May 11, 2023.

Other Expiring Flexibilities

The expiration of the COVID-19 Declaration also will end relief granted during the COVID health care emergency by the Drug Enforcement Agency (“DEA”), the HHS Office of Civil Rights (“OCR”) and other agencies.

For example, the end of the COVID-19 Declaration will end COVID-19 flexibilities for prescribers and others granted by the DEA while the COVID-19 Declaration remained in effect,  See here.

For example, health care providers and their patients may need to plan ahead to avoid unexpected medication and care disruptions that could arise when DEA temporary relief waving requirements for prescribers to register in each state to prescribe across state lines and relief allowing DEA-registered practitioners to issue prescriptions for controlled substances based on telemedicine consultations to patients for whom they have not conducted an in-person medical evaluation ends on May 11, 2023.

Likewise, health care providers also need to make any adjustments in their practices for handling and protecting protected health information needed due to the expiration in COVID-19 related flexibility granted by the HHS Office of Civil Rights (“OCR”) under the COVID-19 Declaration.

Specifically, OCR’s COVID-19 nonenforcement policies like the following also expire when the COVID-10 Declaration ends on May 11, 2023:

• Use of Online or Web-Based Scheduling Applications for the Scheduling of COVID-19 Vaccination Appointments;

• Community-Based Testing Sites;
• Business Associates; and
• Telehealth.

Beyond the expiration of these and other health care specific flexibilities, health care providers, like other businesses also should anticipate and take any necessary steps to confirm their ongoing compliance with any expired or expiring COVID-19 related relief and flexibilities granted on other federal and state employment, heath care, insurance, tax, and other laws in response to the COVID-19 Declaration or other state or local COVID-19 relief.

When reviewing existing practices for required or advisable adjustments in responses to the resolution of the COVID-19 Declaration or other COVID-19 relief, health care providers and other organizations also should assess their potential exposure from other known or potential deficiencies in their overall compliance while their operations were disrupted by the COVID-19 heath care emergency. 

While federal and state agencies provided certain limited flexibility and relief in response to the COVID-19 pandemic, the majority of laws and regulations applicable to health care providers and other businesses remained in effect even as the pandemic shutdown and other disruptions disrupted staffing and other operations necessary reliably to monitor, enforce, document, keep records and perform other critical compliance functions.  Accordingly, many health care and other businesses are funding themselves susceptible to compliant, audits, or other investigations or enforcement actions made by agencies, disgruntled employees, contractors, patients, vendors, or others, or both.  Conducting compliance and risk assessments with these additional requirements within the scope of attorney client privilege may help identify and uncover opportunities to mitigate those exposures.

Enforcement Illustrates Advisability Of Caution

Health care providers are cautioned against overestimated the protection allowed by the COVID-19 flexibilities.  Although the False Claims Act generally allows OIG and the Department of Justice (“”DOJ”) up to 10 years to find and prosecute providers providing care or engaging in other prohibited referrals, kickbacks or other activities, recent enforcement activities make clear the agencies are serious about enforcement against providers acting beyond the scope of the relief.  For instance, an investigation and enforcement against Dr. Musaddiq Nazeeri resulted in his agreement to pay the United States $86,506.30 to resolve civil liability for alleged violations of the False Claims Act  based on DOJ charges that between February 10, 2021 and January 21, 2022, Dr. Nazeeri billed Medicare for certain services that were not supported by the medical record. During the above timeframe, Dr. Nazeeri submitted Evaluation & Management (E&M) claims when the only service rendered was the administration of the COVID-19 vaccine. In the DOJ announcement of the settlement, HHS OIG Special Agent in Charge Maureen R. Dixon warned, “Investigating violations of the False Claims Act is a top priority,”

Bottom line:  health care providers and others involved in providing care, treatment, referrals or other activities covered by the STARK, Fraud & Abuse, or other requirements of Medicare or Medicaid in reliance on flexibilities granted by OIG during the COVID-19 Declaration should cease to rely upon those flexibilities no later than May 11, 2023.  In addition, health care providers are well advised to review any activities conducted in reliance upon these flexibilities during while the COVID-19 Declaration remained in effect to confirm that all conditions to qualify for those flexibilities were met or seek the assistance of legal counsel about whether and what corrective action is advisable.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35+ years of workforce and other management work, public policy leadership and advocacy, coaching, teachings, scholarship and thought leadership.

A Fellow in the American College of Employee Benefit Counsel, Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Chair of the ABA Intellectual Property Section Law Practice Management Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer’s work throughout her 35 year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. As an ongoing component of this work, she regularly advises, represents and defends businesses on Guideline Program and other compliance, risk management and other internal and external controls in a wide range of areas and has published and spoken extensively on these concerns.

Ms. Stamer also is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on workforce, compensation, and other operations, risk management, compliance and regulatory and public affairs concerns.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving, and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2023 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

This week’s announcement of the criminal sentencing of the co-founder of a clinic that pleaded guilty to health care fraud and other federal crimes for involvement in a scheme to defraud self-insured health plans and the Justice Department announcement of its filing of health care fraud and other federal criminal charges against two operators of a chain of substance abuse clinics for their alleged involvement in a scheme to file false claims with private health plans, Medicare and Medicaid remind health care providers and others participating in schemes to defraud private or public health plans risk criminal conviction.

This week, the U.S. District Court for the Western District of Kentucky ordered the co-founder of a that Yesdel Acosta Perez to time served of 14 months in prison and to pay $258,507 in restitution for his role in causing health care clinics he cofounded to bill 15 self-funded health plans for $4.7 million in medical services never provided. The conviction reminds health plans, health care providers and others that fraudulently billing self-insured or other private health plans can result in criminal conviction punishable as felony under multiple provisions of the United States Criminal Code. Acosta Perez’ sentencing coincides with the Justice Department’s announcement of its March 2, 2023 filing of similar criminal charges against the operator of a chain of substance abuse clinics and others for their alleged involvement in millions of dollars of false charges billed to private health plans, Medicare and Medicaid for substance abuse addition treatment not provided.

The conviction and sentencing of Acosta Perez and the newly announced charges against operators of a chain of addiction treatment clinics in Massachusetts and Rhode Island and others for alleged health care fraud aggravated identity theft, money laundering and obstruction in relation to alleged billing of millions of dollars of false charges to private health plans, Medicare and Medicaid for substance abuse treatment by clinics highlight the continuing threat fraudulent actors present for self-insured and other private health plans, Medicare and Medicaid, as well as the potential criminal prosecution and consequences those individuals convicted of these crimes risk from their criminal activity.

Acosta Perez Conviction & Sentencing

The co-founder of Romero Rehabilitation Physical Therapy Inc. and Empire USA Inc. in Louisville and Imaging Group Center Inc. in Atlanta plead guilty to one count of conspiracy to commit healthcare fraud in February, 2023, after the U.S. Department of Labor found the operators collected $258,000 from 15 self-funded healthcare benefit programs for services they never provided based on fraudulent claims made between 2016 and 2018.

In June, 2018, a federal grand jury indicted Acosta Perez and fellow co-founder Eduardo Chinea-Martinez and others on multiple counts of Health Care Fraud in violation of 18 U.S.C. §1347, Theft from a Health Care Benefit Program in violation of 18 U.S.C. §669, Aggravated Identity Theft in violation of 18 U.S 8 U.S.C. §1028A, Money Laundering in violation of 18 U,S,C. §1956, Mail Fraud in violation of 18 U.S.C Chapter 63 and aiding and abetting in the commission of these violations under 18 U.S.C. §1349. billing various healthcare benefit programs through claims administrators Humana, CIGNA and United Healthcare for $4.7 million for services never provided. The U.S. Criminal Code authorized potential sentences of between 10 to 20 years of imprisonment as well as subjected charged defendants to asset forfeiture upon conviction.

The grand jury inditement and subsequent prosecution of Acosta Perz and a fellow co-founder resulted from an Employee Benefit Security Benefit Administration investigation that found that, between May 2015 and January 2016, Acosta Perez and Eduardo Chinea-Martinez co-founded three companies to intentionally defraud various healthcare benefit programs. Investigators also determined Acosta Perez opened bank accounts for the fictitious businesses at JPMorgan Chase Bank, Wells Fargo Bank and Bank of America. Acosta Perez and Chinea-Martinez. The indictment charges that Acosta Perez and Chinea-Martinez misappropriated and used patients’ names, dates of birth, insurance/policy numbers, addresses, and patient IDs/Social Security Numbers, without the patients’ knowledge and names and National Provider Numbers (“NPIs”) from uninvolved doctors without the doctors’ knowledge to create claims for payment by representing these uninvolved doctors and clinics allegedly ordered or performed the services in the false and fraudulent billings submitted by defendants for payment to submit fraudulent claims. The fraudulent claims directed the plans to send payment for the billed services to a Regus virtual office location in Louisville, Kentucky. Acosta Perez then directed Regus via email to forward all mail to Romero Rehabilitation Physical Therapy. According to the indictment, using this process to submit claims for payment for the fraudulent services, Chinea-Martinez and Acosta Perez billed approximately $4,700,000 in fraudulent medical services to the self-insured plans and received payment for $258,000.

In March 2020, the court sentenced Chinea-Martinez to 42 months in prison and three years of supervised release for his part in the scheme. However, before his in June 2018, Acosta Perez fled the U.S. On July 22, 2022, however, the Italian government granted the request of the U.S. for the extradition of Acosta Perez and surrendered him to U.S. authorities. Acosta-Perez was arrested in June 2022.

New Health Care Fraud Charges Against Rhode Island and Massachusetts Addiction Treatment Chain Operators

Acosta-Perez’s sentencing coincides with the Justice Department’s March 2, 2023 announcement of its filing of a host of similar charges in Rhode Island against the operator of a chain of addiction treatment clinics and others for alleged aggravated identity theft, money laundering and obstruction in relation to theft of the identities and other patient and provider information and using their information to file false charges billed to private health plans, Medicare and Medicaid for substance abuse treatment by clinics.

Michael Brier, Mi Ok Bruining and Recovery Connections Centers of America, Inc. (RCCA) are charged in a federal criminal complaint with health care fraud and Michael Brier also is charged with aggravated identity theft, money laundering and obstruction. In addition, the treatment center and its former supervisory counselor were also charged with health care fraud. The Justice Department announcement of these charges reminds readers that its federal criminal complaint is merely an accusation and that the defendants are presumed innocent unless and until proven guilty.

The Justice Department alleges in court documents that, Brier, Bruining, and RCCA shortchanged Rhode Island and Massachusetts substance abuse disorder patients out of much needed counseling and treatment services, while defrauding Medicare, Medicaid, and other health insurers out of millions of dollars.

According to the charging documents, Brier, Bruining and RCCA operated a chain of addiction treatment centers but failed to provide the patients with the required counseling sessions and treatment, while simultaneous billing Medicare, Medicaid and other health care payors for 45-minute counseling sessions on a routine basis even though the sessions were not more than 15 minutes, and often only 5-10 minutes or less.  At times, so many counseling sessions were billed at this level that the total amount of time would be impossible for the available therapist to have provided in any 24 hours period. 

Brier and RCCA are also alleged to have caused a fraudulent application to be submitted to Medicare which, among other things, misrepresented and concealed the role that Brier was playing in the business and failed to disclose Brier’s 2013 criminal conviction for federal tax crimes, which was relevant to Medicare’s consideration of the application. 

The Complaint also alleges that Brier purported to practice medicine and wrote and caused to be filled fraudulent prescriptions using the names and prescriber information, including Drug Enforcement Administration numbers, of doctors without their permission.

Brier is also alleged to have falsified a document in a matter within the jurisdiction of an agency of the United States by causing the Medical Director to sign a false and back-dated document.

The complaint alleges that defendants caused millions of dollars in fraudulent billings to be submitted to Medicare and millions more in fraudulent billings to other health care payors. The government is also seeking to forfeit thirteen bank accounts, two buildings, and two vehicles allegedly realized by the defendants as a result of the alleged criminal conduct.

The two prosecutions highlight the serious criminal consequences that health care providers or others participating in schemes to defraud employer or union sponsored self-insured health plans, group or individual health insurance, Medicare, Medicaid or other public or private health care programs can face under a host of federal criminal statutes. The felony liability imposed under these statutes makes it critical that health care providers, payers and other organizations involved in providing or billing for health care services both ensure that their programs are designed and administered to be legally defensible as well as to guard against the misuse of their systems, operations or data by insiders from misappropriating and using their systems, practices or data for illicit billing or other fraudulent purposes.

To maintain and promote the effectiveness of these efforts, organizations and their leaders also should consider the advisability of enhancing these fraud and other compliance efforts, as well as updating their organization’s Federal Sentencing Guideline and other compliance programs and practices in light of the new corporate criminal conduct Voluntary Self-Disclosure Policy (“VSD policy”) announced by the Department of Justice on February 23, 2023. Concurrently, organizations and their leaders also will want to monitor and respond promptly to Justice Department statements and congressional recommendations on proposed Guideline changes providing critical insights into the Justice Department’s planned interpretation and enforcement of federal criminal laws and the Guidelines against organizations and their leaders like those available here. For more information about the VSD policy and its implications on your organization under the Federal Sentencing Guidelines, see Ensure Health Care & Other Compliance Practices Updated For New DOJ Voluntary Disclosure Policy.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35+ years of workforce and other management work, public policy leadership and advocacy, coaching, teachings, scholarship and thought leadership.

A Fellow in the American College of Employee Benefit Counsel, Vice Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer’s work throughout her 35 year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. As an ongoing component of this work, she regularly advises, represents and defends businesses on Guideline Program and other compliance, risk management and other internal and external controls in a wide range of areas and has published and spoken extensively on these concerns.

Ms. Stamer also is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on workforce, compensation, and other operations, risk management, compliance and regulatory and public affairs concerns.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving, and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2023 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

Former Missouri state representative Patricia “Tricia” Ashton Derges was sentenced in federal court for a nearly $900,000 COVID-19 fraud scheme, as well as a separate $200,000 fraud scheme in which she made false claims about a fake stem cell treatment marketed through her clinics in southern Missouri, and for illegally providing prescription drugs to clients of those clinics.

U..S. District Judge Brian C. Wimes sentenced Derges to six years and three months in federal prison without parole and ordered Derges to pay $500,600 in restitution to her victims.

“Derges exploited her position as an elected official and a medical professional to benefit herself financially with complete disregard, to not only her constituents, but to the oath she took as a health care professional to do no harm,” said Charles Dayoub, Special Agent in Charge of FBI Kansas City. “She not only fraudulently received nearly $300,000 in CARES Act funds, but also deceived patients by marketing fake stem cell treatment and illegally provided drugs to clients of her clinics. Her actions were a betrayal of trust, eroding the very core of our confidence in a system we rely on and damaging the public’s trust not only in our elected officials but in our health care system.”

Derges was elected in November 2020 as a Missouri state representative in District 140 (Christian County) and served one term. Derges, who was never a physician, surrendered her physician’s assistant license on June 29, 2023. Derges formerly operated three for-profit Ozark Valley Medical Clinic locations in Springfield, Ozark, and Branson, Mo. Derges also operated the non-profit corporation Lift Up Someone Today, Inc., with a medical and dental clinic in Springfield.

COVID-19 Fraud Scheme

Derges was convicted of three counts of wire fraud related to her attempt to fraudulently receive nearly $900,000 in CARES Act funds. Derges actually was awarded $296,574 in CARES Act funds for Lift Up, although Lift Up did not provide any COVID-19 testing services to its patients. In fact, Lift Up’s medical clinic closed at the beginning of the COVID-19 pandemic and remained closed from March to June 2020.

Derges sought CARES Act funding for COVID-19 testing that had been provided, and already paid for, at her for-profit Ozark Valley Medical Clinic. Derges requested reimbursement for $379,294 in COVID-19 testing and related expenses, and future funding in the amount of $503,350. In total, Derges applied for $882,644 from the CARES Act Relief Fund on Lift Up’s behalf.

Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act in March 2020, which provided $150 billion to states, tribal governments, and units of local government. Missouri was allocated approximately $2.3 billion. Missouri allocated approximately $34 million in CARES Act funds to Greene County. To administer the CARES Act funds it received, the Greene County Commission created the CARES Act Relief Fund to “promote recovery by funding programs and services that support the needs of those impacted by the COVID-19 public health emergency.” An advisory council of 30 citizen volunteers was appointed to review funding requests and make funding recommendations to the Greene County Commission.

Derges claimed in her application to the Greene County CARES Act Relief Fund that Lift Up provided COVID-19 testing and sought reimbursement for “COVID-19 eligible expenses” that Lift Up had incurred. To support her claim, Derges provided invoices totaling $296,574 from Dynamic DNA for more than 3,000 COVID-19 laboratory tests. Derges submitted the Dynamic DNA invoices as Lift Up expenditures, although they were actually for testing done at Derges’s for-profit Ozark Valley Medical Clinic.

Lift Up, a non-profit charity, and Ozark Valley Medical Clinic, a for-profit corporation, are separate legal entities. Ozark Valley Medical Center had already received payment from its clients of approximately $517,000 for these COVID-19 tests. Ozark Valley Medical Center charged clients, patients, or their patients’ employers approximately $167 per sample for its COVID-19 testing services. Derges concealed from Greene County that these COVID-19 tests had already been paid for by other payors.

In December 2020, the Greene County Commission awarded Lift Up $296,574 in CARES Act funding based upon Lift Up’s fraudulent application and the Dynamic DNA invoices Derges had submitted. Derges deposited the check into Lift Up’s bank account, then transferred the funds into Ozark Valley Medical Center’s bank account.

Derges provided several more invoices from Dynamic DNA to Greene County later in December 2020 to further support her application for Lift Up, although the invoices were actually for testing done for clients at Ozark Valley Medical Center, raising the total to $589,143 for 6,177 COVID-19 tests. Derges concealed from Greene County that Ozark Valley Medical Center already had been paid approximately $1 million by clients, patients, or their patients’ employers, for these COVID-19 tests.

Stem Cell Fraud Scheme

Derges also was convicted of seven counts of wire fraud related to a nearly $200,000 fraud scheme, which lasted from December 2018 to May 2020. Derges marketed a stem cell treatment that actually utilized amniotic fluid that did not contain any stem cells. The federal indictment charged her with defrauding four specific victims, each of whom testified during the trial.

Derges exclusively obtained amniotic fluid from the University of Utah, which she marketed under the name Regenerative Biologics. Derges advertised Ozark Valley Medical Clinic as a “Leader in … Regenerative Medicine,” including stem cells, and marketed her “stem cell” practice through seminars, media interviews, and social media. Derges made similar claims in personal consultations.

In fact, however, the amniotic fluid Derges administered to her patients did not contain mesenchymal stem cells, or any other stem cells. The amniotic fluid she obtained from the University of Utah was a sterile filtered amniotic fluid allograft (a tissue graft comprised of human amniotic membrane and amniotic fluid components derived from placental tissue). The amniotic fluid allograft was “acellular,” meaning it did not contain any cells, including stem cells.

Despite being told by the University of Utah that the University of Utah’s amniotic fluid allograft was “acellular” and did not contain mesenchymal stem cells, Derges continued to tell her patients and the public that the amniotic fluid allograft contained stem cells.

Derges administered amniotic fluid, which she falsely claimed contained stem cells, to patients who suffered from, among other things, tissue damage, kidney disease, chronic obstructive pulmonary disease (COPD), Lyme disease, and urinary incontinence. In an April 11, 2020, Facebook post Derges wrote of amniotic fluid allograft: “This amazing treatment stands to provide a potential cure for COVID-19 patients that is safe and natural.”

The University of Utah sold its amniotic fluid allograft to Derges for approximately $244 per milliliter and $438 for two milliliters. Derges charged her patients $950 to $1,450 per milliliter. In total, Derges’s patients paid her approximately $191,815 for amniotic fluid that did not contain stem cells.

Controlled Substances Act

Derges also was convicted of 10 counts of distributing Oxycodone and Adderall over the internet without valid prescriptions. Derges, without conducting in-person medical evaluations of the patients, wrote electronic prescriptions for Oxycodone and Adderall for patients and transmitted them to pharmacies over the internet.

Because none of the assistant physicians whom Derges employed at Ozark Valley Medical Clinic could prescribe Schedule II controlled substances, it was the standard practice of the assistant physicians to see a patient and later communicate to Derges the controlled substances they wanted her to prescribe to their patients. Derges, without conducting an in-person medical evaluation of the patients as required by federal law, wrote electronic prescriptions for the patients and transmitted the prescriptions over the internet to pharmacies.

False Statements

Derges also was convicted of two counts of making false statements to federal agents investigating this case in May 2020.

Derges told agents that the amniotic fluid allograft that she used in her practice contained mesenchymal stem cells, which she knew was false. Derges also told federal agents that she had not treated a patient for urinary incontinence with amniotic fluid allograft, which she knew was false.

Convictions

On June 28, 2022, Derges was found guilty at trial of 10 counts of wire fraud, 10 counts of distributing drugs over the internet without a valid prescription, and two counts of making false statements to a federal law enforcement agent.

The convictions remind other healthcare providers, their practices and their leaders of the risks of violating federal, false claims act and other laws in relation to the practice of healthcare and investigations of fraud, or other misconduct connected to their practices. healthcare providers, or healthcare practices that suspect that they or others practicing as their employee, practitioners or agents have engaged in these or other violations of federal healthcare laws should contact counsel to explore their responsibilities and potential liability under the Federal Sentencing Guidelines, and other laws.

More Information

When investigating and responding to a violation, it is critically important to document the timing and details of the discovery of a potentially concern

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35+ years of workforce and other management work, public policy leadership and advocacy, coaching, teachings, scholarship and thought leadership.

A Fellow in the American College of Employee Benefit Counsel, Vice Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer’s work throughout her 35 year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. As an ongoing component of this work, she regularly advises, represents and defends businesses on Guideline Program and other compliance, risk management and other internal and external controls in a wide range of areas and has published and spoken extensively on these concerns.

Ms. Stamer also is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on workforce, compensation, and other operations, risk management, compliance and regulatory and public affairs concerns.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving, and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2023 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

New policy guidance issued by the U.S. Citizenship and Immigration Services (“ICE”) could impact employment options of medical, nursing, technology and other foreign students options for work under F-1 student visas.

ICE’s new guidance clarifies the validity period of employment authorization for F-1 nonimmigrant students experiencing severe economic hardship due to emergent circumstances (also known as special student relief (SSR)) who are work authorized under the SSR provisions of 8 CFR. Health care and other organizations should note the update both to recognize the students’ expanded eligibility to work to avoid improper discrimination against foreign student applicants and as prospects for worker hires.

The policy update to the USCIS Policy Manualclarifies that in cases of severe economic hardship due to emergent circumstances, ICE may grant off-campus SSR employment authorization to an F-1 nonimmigrant student for the duration of the Federal Register notice validity period, which is typically 18-months. However this employment authorization may not extend past the student’s academic program end date..

Emergent circumstances are events that affect F-1 nonimmigrant students from a particular region and create severe economic hardship. These events may include, but are not limited to, natural disasters, financial crises, and military conflicts.

This policy update will be effective when published and will apply to all pending and future applications for SSR employment authorization.  

More Information

We hope this update is helpful. For more information about the these or other workforce or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and managed care and employer benefits legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her 30 plus year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. Her work has included ongoing involvement in health industry and workforce competition and antitrust issues. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

IMPORTANT NOTICE FOR ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication. 

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2023 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

Nine Texas individuals were arrested this week in Houston on criminal charges related to their alleged involvement in the unlawful distribution of 1.5 million opioid pills and other controlled substances as a result of a joint federal-state investigation. 

According to court documents, Kent Lyons, 52, of Houston; Roquel Turner, 47, of Manvel; and Traunce Alfred, 43, of Baytown, are charged with illegally distributing controlled substances, including oxycodone and hydrocodone. From August 2017 until late 2022, Lyons and Turner allegedly operated pill-mill pharmacies as fronts to obtain opioids in their highest-strength and immediate-release pill form. They then allegedly sold the drugs on the black market – without the involvement of patients, prescriptions, or doctors – to drug traffickers like Alfred. Lyons and Turner allegedly concealed the drug proceeds using numerous bank accounts and real estate transactions. Lyons also allegedly used some of the proceeds to purchase luxury items, including a Rolls Royce, a Ford F-250, and a Mercedes Maybach.

Court documents allege starting around December 2020, Dwain Ross and Delores Mackey-Ross both of Pearland, and licensed pharmacist Ann Nguyen, of Stafford, allegedly used pharmacies to illegally distribute and dispense nearly half a million pills of oxycodone and hydrocodone. Dwain Ross and Mackey-Ross and David Ross of Houston; Kevin Peterson of Pearland; and Eleanor Marsh of Fulshear, also allegedly illegally ordered the opioid potentiators alprazolam, carisoprodol, promethazine with codeine – which are reported to enhance the high from opioids – from a pharmaceutical wholesaler and a pharmaceutical sales representative then allegedly illegally distributed the opioid potentiators in bulk. Dwain Ross and Mackey-Ross allegedly used numerous bank accounts and real estate transactions to conceal their ill-gotten gains. Dwain Ross also allegedly used some of the drug proceeds to purchase a Lamborghini.

The pharmacies alleged in the indictments to have been controlled by the defendants’ drug trafficking organizations are K Med Pharmacy, Nex Gen Pharmacy, TX United Pharmacy, Power Center Pharmacy #2, DR Pharmacy, and Nu Care Pharmacy. Several other pharmacies, including P&A Pharmacy and Pearland Holistic Pharmacy, voluntarily surrendered their DEA Registration numbers, which a pharmacy needs to legally purchase pharmaceutical opioids and other controlled substances.

Lyons, Turner, Alfred, Dwain Ross, Mackey-Ross, and Nguyen are each charged with illegal distribution of Schedule II opioids. Dwain Ross, Mackey-Ross, David Ross, Peterson, and Marsh are each charged with the illegal distribution of Schedule IV drugs. Lyons, Turner, Dwain Ross, and Mackey-Ross are also charged with money laundering crimes.

Regardless of the ultimate outcome of the current charges, the indictments demonstrate the continuing commitment by the Department of Justice and other federal and state agencies to investigate and prosecute opiate prescription and distribution.

If convicted, Lyons, Turner, Alfred, Dwain Ross, Mackey-Ross, and Nguyen face up to 20 years on the top counts. David Ross and Peterson each face up to five years. Marsh faces up to 10 years if convicted. Court documents allege that over 15 bank accounts, four real properties, and several luxury vehicles – including a Rolls Royce, a Bentley, and a Lamborghini – were involved in, or acquired with proceeds from, the scheme, and are subject to forfeiture if the defendants are convicted.

Of course, the facts alledged in the indictments are allegations ll defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law. If a conviction happens, a federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Regardless of the outcome, the prosecution demonstrates the prioritization of the investigation and prosecution of abusive opiate prescribing or distribution.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and managed care and employer benefits legal, public policy and operational concerns.

Ms. Stamer’s work throughout her 30 plus year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication. 

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2023 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

Children’s Healthcare of Atlanta (CHOA), a pediatric healthcare system in Georgia, faces a religious discrimination lawsuit filed by U.S. Equal Employment Opportunity Commission (EEOC) that charges CHOA violated federal law by firing a maintenance assistant for requesting a religious exemption to its influenza vaccination policy. The suit illustrates the narrow tightrope health care providers walk negotiating vaccination and other COVID-19 safety protocols without violating religous accommodation or other employment discrimination requirements.

Title VII of the Civil Rights Act of 1964 prohibits firing an employee because of his religion and requires that employers accommodate sincerely held religious beliefs unless the employer proves accommodation would impose an undue hardship. EEOC COVID guidance warns employers of the EEOC’s interpretation of the continued applicability of Title VII’s religous accommodation requirements to employers enforcement of COVID and other vaccine mandates. Other related guidance also warns employers to avoid retaliation against employees for expressing religous objections to vaccination policies or engaging in other protected actions in violation of Title VII.

The EEOC’s suit states the maintenance employee, in accordance with CHOA’s procedures, requested a religious exemption to CHOA’s flu vaccination requirements based on sincerely held religious beliefs. CHOA previously granted the employee a religious exemption in 2017 and 2018. In 2019, however, CHOA changed its policy and denied the employee’s request for a religious accommodation and fired him, despite the employee’s extremely limited interaction with the public or staff.

The EEOC asserts it would not have been an undue burden for CHOA to continue accommodating its employee as it had in 2017 and 2018. However it instead changed its stance on flu vaccination exemptions for this maintenance employee in 2019 and failed to consider any meaningful reasonable accommodations for his sincerely held religious beliefs.

Charging the refusal to grant accommodation arges this alleged conduct violates Title VII, the EEOC filed suit (Civil Action No. 1:22-CV-4953 MLB RDC) in U.S. District Court for the Northern District of Georgia, Atlanta Division, after first attempting to reach a pre-litigation settlement via its conciliation process. The EEOC lawsuit seeks back pay, front pay, compensatory damages and punitive damages for the employee, as well as injunctive relief to prevent future discrimination.

The suit against CHOA follows through on the EEOC’s commitment to investigate and enforce Title VII against employees failing to grant exemptions to otherwise applicable COVID or other vaccination requirements to employees with sincerely held religous beliefs against vaccination unless the employer proved undue hardship preventing the accommodation. 

The lawsuit warns health industry and other employers with vaccination requirements to provide accommodations for employees with deeply held religous beliefs against the vaccine unless the employer can prove undue hardship sufficient to excuse the accommodation. The prosecution of the suit against a health care organization subject to the tightest vaccination and other COVID safety mandates under Centers for Disease Control, the Centers for Medicare & Medicaid Services and Occupational Safety & Health Administration regulations demonstrates the high burden the EEOC expects employers refusing accommodation to meet. In light of these EEOC CHOA and other enforcement actions, employers should proceed carefully before refusing accommodation. See e.g., CMS Updates COVID-19 Guidance For Visiting Nursing Homes & LTC Facility Vaccination During Omicron Surge; CMS/CDC Mandating COVID Vaccination For All Nursing Home Staff; Health Provider Fined $273K+ For COVID Safety Violations; Dentists Face OSHA Retaliation Suit For Retaliating Against Workers Asking About COVID Safety. As COVID and other pandemic and epidemic outbreaks continue to threaten health care worker, patients and community safety, organizations must tred carefully and be prepared to defend the adequacy of their actions regardless of whether choosing to allow or deny accommodation from applicable communicable disease protocols.

For Help With Comments, Investigations Or The Other Needs

If your organization would like to learn more about the concerns discussed in this update or seeks assistance auditing, updating, administering or defending its human resources, compensation, benefits, corporate ethics and compliance practices, or other performance related concerns, contact management attorney and consultant Cynthia Marcotte Stamer.

An attorney Board Certified in Labor & Employment Law by Texas Board of Legal Specialization, Ms. Stamer is recognized for work helping organizations management people, operations and risk as  a Fellow in the American College of Employee Benefit Counsel, a “Top Woman Lawyer,” “Top Rated Lawyer,” and “LEGAL LEADER™” in Labor and Employment Law and Health Care Law; a “Best Lawyers” in “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law.”

For 35 years, Ms. Stamer’s work has focused on advising and assisting businesses and business leaders with these and other employment and other staffing, employee benefit, compensation, risk, performance and compliance management and other operational solutions and concerns. Her experience includes helping management both manage performance and manage legal risk and compliance.  While helping businesses define and manage the conduct and performance of their employees, contractors and vendors, she also assists employers and others about compliance with federal and state equal employment opportunity, compensation, health and other employee benefit, workplace safety, leave, and other labor and employment laws, advises and defends businesses against labor and employment, employee benefit, compensation, fraud and other regulatory compliance and other related audits, investigations and litigation, charges, audits, claims and investigations by the IRS, Department of Labor, Department of Justice, SEC,  Federal Trade Commission, HUD, HHS, DOD, Departments of Insurance, and other federal and state regulators. Ms. Stamer also speaks, coaches management and publishes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

Other Helpful Resources & Information

If you found this article of interest, you also may be interested in reviewing other Breaking News, articles and other resources available including:

• ADA May Require Employers To Accommodate Employees Testing Positive For Legally Prescribed Medications
• Selected Thoughts And Other Resources On Evolving U.S. Department Of Justice Antitrust Policy On Prescription Medical & Other Health Products Pricing & Competition; Surprise Billing; And Novel Coronavirus Planning & Response
• HR & Benefit Leadership Resilience Strategies For Leading Your People & Operations Through COVID-19 Uncertainties & Disruptions
• OSHA Nails NJ Transitional Housing Provider For Exposing Workers To COVID-19
• SEC Proposed Cybersecurity Rules Reenforce Tighten Requirements & Highlight Imperative For Market Involved & Influencing Businesses & Leaders To Clean Up Cybersecurity Practices & Disclosures
• Raise Cybersecurity & Cyberbreach Compliance & Risk Management To Defend Against Rising Cyber Regulatory & Enforcement Risks
• DOJ Civil Cyber-Fraud Initiative Pressures Federal Contractors & Grant Recipients To Tighten Cybersecurity Controls, Training & Other Safeguards
• Eased Opiate Prescription Guidelines Could Impact Employers & Health Plans
• Government Contractors Update OFCCP workplace Posters
• EEOC Sues Lilly USAA For Age Discrimination
• Per Diem Travel Reimbursement Rate Changing
• OFCCP Revises Functional Affirmative Action Program Directive
• Impact on Governmental  Policy on Pricing And Access to Prescription Medical Products in the Market Place
• $1.1 Million In DOJ Penalties Show Businesses Risks Of National Origin/Citizenship Discrimination In Job Postings and Other Employment Practices
• OFCCP Extends Deadline For Contractors Objection To EEO-1 Reports FOIA Release
• 5 Ex-Methodist Hospital Employees Charged with Criminal HIPAA Violations
• Pharmacies Pay $6.8+ Million To Settle False Claims Act Civil Claims
• OCR Dental Practices Settlements Warn Providers To Honor HIPAA Access Rights
• Criminal IV Tampering Charges Against Anesthesiologist Highlight Exposures Providers And Their Facilities Can Face From Team Members Retaliatory or Other Misdeeds
• Act Promptly To Comment On ONC’s Proposed Electronic Clinical Quality Measure Draft Changes
• HIPAA Covered Entity Nailed With $300,000+ HIPAA Settlement For Improper PHI Disposal
• Protect Remote Desktop Protocols From Malware Threat
• SCOTUS: Emotional Injury Damages Not Recoverable In Patient’s Private Rehab Act and ACA Disability Discrimination Lawsuit But Other Significant Liability Risks Remain
• Justice Department Antitrust Suit Seeks To Block UnitedHealth Acquisition Of Change Healthcare As Anticompetitive
• ERISA Claims and Appeals ERISA Basics Bootcamp
• CMS Updates COVID-19 Guidance For Visiting Nursing Homes & LTC Facility Vaccination During Omicron Surge
• Justice Department COVID & Other Health Care Fraud Enforcement Thriving Despite Pandemic Emergency
• Confirm Health & Fitness App Breach & Security In Face Of New Enforcement Risks
• Biden-Harris Administration to Expand Vaccination Requirements for Health Care and Many Other Employers

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here. For important information concerning this communication click here.  If you do not wish to receive these updates in the future, unsubscribe by updating your profile here.

NOTICE: Terms. These materials are for general informational and educational purposes only. They do not establish an attorney-client relationship, are not legal advice, a substitute for legal advice, an offer or commitment to provide legal advice or an admission. The information and statements in these materials may not address all relevant issues or apply to any situation or circumstances. The author reserves the right to qualify or retract any of these statements at any time. and does not necessarily address all relevant issues. Because the law evolves and in ways that subsequent developments could impact the currency and completeness of this discussion. The author disclaims and has no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers are urged to engage competent legal counsel for consultation and representation considering the specific facts and circumstances presented in their unique circumstance at any time. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication. Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein. ©2022 Cynthia Marcotte Stamer. Nonexclusive right to republish granted to Solutions Law Press, Inc. All other rights reserved.

The November 1, 2022 American Bar Association Tort Trial & Insurance Section Medicine & Law Committee November Learning Session will focus on the details and likely implications of the groundbreaking August 8, 2022 settlement of the long-running In Re Blue Cross And Blue Shield Litigation on the commercial health insurance market and the health care provider contracting, payment and other relations by Blue Cross Blue Shueld Association and its member insurers.

The August 8, 2022 settlement requires the Association and its members to make substantial changes in longstanding market and business practices that have helped the Association and its member insurance organizations establish and protect their market dominance from external and internal competition, and use that market dominance in its contracting and other dealings with health care providers.

After nine years of litigation challenging the provider contracting and business contracting rules and practices of the Association as anticompetitive, the reforms by the Association and its member insurance organizations agreed upon in the settlement agreement are expected to foster freer market competition of insurance products and services to customers, and provide health care providers greater strength when dealing with the Association and its members on provider contracting and claims.  Meanwhile, the more than nine years of litigation leading up to the settlement produced several significant procedural and substantive rulings likely to shape future antitrust litigation.

During Tuesday’s Committee Learning Session, Medicine & Law Committee Chair-Elect Cynthia Marcotte Stamer, Managing Shareholder, Cynthia Marcotte Stamer, P.C. will share a brief overview and selected resources about the litigation and settlement, before leading a discussion among call participants of their thoughts about the significance and implications of these developments on the marketplace and future antitrust litigation and enforcement. 

For more information about the Learning Session or other opportunities for involvement with the Medicine & Law Committee, e-mail Chair Elect Cynthia Marcotte Stamer or see the Medicine & Law Committee webpage.

Unemployment is slightly up according to just released U.U. Department of Labor (“DOL”) data.

DOL reports the advance figure for seasonally adjusted initial claims rose by 9,000 from 235,000 to 244,000, In the week ending July 9, 2022. The 4-week moving average was 235,750, an increase of 3,250 from the previous week’s unrevised average of 232,500.

Review the latest data here.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication. 

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2022 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

Watch for the Department of Health & Hunan Services (“HHS”) to step up scrutiny and regulation of non-hospice reimbursements for hospice care in response to recommendations from a just-announced Office of Inspector General (“OIG”) findings of cost increases.

OIG’s analysis of trends and patterns in payments for items and services provided to Medicare beneficiaries outside the Medicare hospice benefit during a hospice period of care (“nonhospice payments”) showed an increase in Medicare nonhospice payments for beneficiaries. Nonhospice payments for Medicare Part A services and Part B items and services totaled $6.6 billion from 2010 through 2019. OIG is concerned if providers bill Medicare for nonhospice items and services that potentially should be covered by hospices, Medicare could pay for the same items or services twice.

Learn more about the OIG findings at Medicare Payments of $6.6 Billion to Nonhospice Providers Over 10 Years for here and Services Provided to Hospice Beneficiaries Suggest the Need for Increased Oversight

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

Past Board President of the Richardson Development Program for Children ECE and Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, Vice Chair of the ABA International Section Life Sciences Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her 30 plus year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication. 

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2022 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

The National Science Advisory Board for Biosecurity (NSABB) is scheduled to virtually meet via video cast on February . 28, 2022, from 12 p.m. – 1 p.m. EST to discuss next steps for the committee in fulfilling its purpose to provide advice, guidance and recommendations to the U.S. government regarding biosecurity oversight of dual use research.

In January 2020, the NSABB was charged with providing recommendations on balancing security and public transparency when sharing information about research with enhanced potential pandemic pathogens (ePPP). The board was also tasked with evaluating and analyzing the U.S. Dual Use Research of Concern (DURC) policies. Due to the rapid escalation of the COVID-19 pandemic, the activities of the NSABB were paused to allow members to prioritize response activities at their home institutions.

The NSABB is being reconvened to help ensure that the U.S. government oversight framework is keeping up with rapid advances in science that may raise biosecurity concerns.

Interested persons should tune in.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

Past Board President of the Richardson Development Program for Children ECE and Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, Vice Chair of the ABA International Section Life Sciences Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her 30 plus year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

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NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author and Solutions Law Press, Inc.™ reserve the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law is rapidly evolving and rapidly evolving rules makes it highly likely that subsequent developments could impact the currency and completeness of this discussion. The author and Solutions Law Press, Inc.™ disclaim, and have no responsibility to provide any update or otherwise notify anyone any such change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication. Readers acknowledge and agree to the conditions of this Notice as a condition of their access of this publication. 

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2022 Cynthia Marcotte Stamer. Limited non-exclusive right to republish granted to Solutions Law Press, Inc.™

The Centers for Medicare & Medicaid Services (CMS) has published an update to the 2022 CMS Quality Reporting Document Architecture (QRDA) Category III Implementation Guide (IG) and Sample Files (zip). The 2022 CMS QRDA III IG outlines requirements for eligible clinicians and eligible professionals to report electronic clinical quality measures for the calendar year (CY) 2022 performance period.

The updates include:

• CMS added to Table 14: UUID List for MIPS 2022 CY Performance Period eCQM Specifications Eligible Professionals and Eligible Clinicians
  • The missing UUID of population 2 numerator exclusion for CMS156v10. This issue was reported in QRDA Known Issue QKI-6
  • Missing measure CMS646v2
• CMS added these tables based on the CY 2022 Medicare Physician Fee Schedule Final Rule.
  • Table 15: Improvement Activities Identifiers for the MIPS CY 2022 Performance Period
  • Table 16: Promoting Interoperability Objectives and Measures Identifiers for the MIPS CY 2022 Performance Period
  • Table 17: Promoting Interoperability Attestation Statements Identifiers
• CMS also made minor edits to the 2022 CMS QRDA III Sample Files header comments.

Find additional QRDA-related resources, as well as current and past IGs, on the Electronic Clinical Quality Improvement (eCQI) Resource Center QRDA page. For questions related to this guidance, the QRDA IGs, or Schematrons, visit the ONC Project Tracking System (Jira) QRDA project. See the QRDA Known Issues Dashboard for solutions under development for both QRDA I and III known technical issues. These known issues supplement the information in QRDA IGs and other supporting documents.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.  

About the Author

Recognized as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

Past Board President of the Richardson Development Program for Children ECE and Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, Vice Chair of the ABA International Section Life Sciences Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group and the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her 30 plus year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. 

As a part of this work, she has continuously and extensively worked with domestic and international health plans, their sponsors, fiduciaries, administrators, and insurers; managed care and insurance organizations; hospitals, health care systems, clinics, skilled nursing, long term care, rehabilitation and other health care providers and facilities; medical staff, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; EHR, claims, payroll and other technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies. 

This involvement encompasses helping health care systems and organizations, schools, ECEs, group and individual health care providers, health plans and insurers, health IT, life sciences and other health industry clients prevent, investigate, manage and resolve sexual assault, abuse, harassment and other organizational, provider and employee misconduct and other performance and behavior; manage Section 1557, Civil Rights Act and other discrimination and accommodation, and other regulatory, contractual and other compliance; vendors and suppliers; contracting and other terms of participation, medical billing, reimbursement, claims administration and coordination, Medicare, Medicaid, CHIP, Medicare/Medicaid Advantage, ERISA and other payers and other provider-payer relations, contracting, compliance and enforcement; Form 990 and other nonprofit and tax-exemption; fundraising, investors, joint venture, and other business partners; quality and other performance measurement, management, discipline and reporting; physician and other workforce recruiting, performance management, peer review and other investigations and discipline, wage and hour, payroll, gain-sharing and other pay-for performance and other compensation, training, outsourcing and other human resources and workforce matters; board, medical staff and other governance; strategic planning, process and quality improvement; meaningful use, EHR, HIPAA and other technology, data security and breach and other health IT and data; STARK, ant kickback, insurance, and other fraud prevention, investigation, defense and enforcement; audits, investigations, and enforcement actions; trade secrets and other intellectual property; crisis preparedness and response; internal, government and third-party licensure, credentialing, accreditation, HCQIA and other peer review and quality reporting, audits, investigations, enforcement and defense; patient relations and care; internal controls and regulatory compliance; payer-provider, provider-provider, vendor, patient, governmental and community relations; facilities, practice, products and other sales, mergers, acquisitions and other business and commercial transactions; government procurement and contracting; grants; tax-exemption and not-for-profit; privacy and data security; training; risk and change management; regulatory affairs and public policy; process, product and service improvement, development and innovation, and other legal and operational compliance and risk management, government and regulatory affairs and operations concerns. to establish, administer and defend workforce and staffing, quality, and other compliance, risk management and operational practices, policies and actions; comply with requirements; investigate and respond to Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry actions: regulatory and public policy advocacy; training and discipline; enforcement; and other strategic and operational concerns. 

Author of a multitude of health industry and other highly regarded publications and presentations, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources available here.  

IMPORTANT NOTICE ABOUT THIS COMMUNICATION

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general informational and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique circumstance at any particular ti