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$12M+ Settlement Recoveries In 2 Health Care Fraud Whistleblower Claims Shows Providers, Owners, Management & Staff Must Manage Compliance & Risks

November 23, 2012

The Justice Department’s announcement that it will recover more than $11.3 million in False Claims Act recoveries under two settlements announced on November 20, 2012 provides yet another sharp reminder to health care providers of the critical need to carefully manage billing, referral and other practices to manage health care fraud related exposures.

On November 20, the Justice Department announced that Morton Plant Mease Health Care Inc. and its affiliated hospitals (Morton Plant) will pay $10,169,114 to the federal government to resolve allegations that Morton Plant facilities violated the False Claims Act by submitting false claims for services rendered to Medicare patients. The same day, the Justice Department also announced its achievement of a $1.286 million settlement with Harmony Care Hospital, Inc. and its owner Harmony Care Hospice Inc. (Harmony) and Harmony owner and chief executive officer Daniel J. Burton of allegations that the South Carolina-based company submitted false claims to Medicare for patients under care at its hospice facilities.

Both settlements show the role that disgruntled current or former employees or other whistleblowers increasingly play in these and other health care fraud investigations as well as the significant exposures that health care providers, their owners and management risk by engaging or failing to investigate and resolve practices that Federal officials consider to violate the False Claims Act or other federal health care fraud laws.

Morton Plan Settlement

The Morton Plant settlement resolves whistleblower allegations that, between July 1, 2006 and July 31, 2008, Morton Plant improperly billed for certain interventional cardiac and vascular procedures as inpatient care when those services should have been billed as less costly outpatient care or as observational status. See United States ex rel. Randi Ferrare v. Morton Plant Mease Health Care, Inc., No. 08:cv:01689-T-266MSS (M.D. Fl.).

Morton Plant owns and operates, or is affiliated with, Morton Plant Hospital, St. Joseph’s Hospital, Morton Plant North Bay Hospital, St. Anthony’s Hospital, Mease Countryside Hospital and Mease Dunedin Hospital. These hospitals are part of the BayCare Health System in Florida’s Pinellas, Hillsborough and Pasco counties.

The Morton Plant action arose from a qui tam, or whistleblower, lawsuit filed by Randi Ferrare, a former director of Health Management Services at Morton Plant Hospital. Under the False Claims Act, private citizens, known as relators, can bring suit on behalf of the United States and share in any recovery. Ms. Ferrare will receive over $1.8 million as her share of the government’s recovery.

Harmony $1.2 Million Settlement

The Harmony settlement arises out of a qui tam action filed against Harmony Care Hospice Inc. (Harmony) and Harmony owner and chief executive officer Daniel J. Burton have agreed to pay the United States $1,286,999.32 to settle allegations that the South Carolina-based company submitted false claims to Medicare for patients under care at its hospice facilities.

The Harmony settlement resolves a lawsuit filed by former Harmony employees Mona Singletary and Lynda Fulton under the qui tam, or whistleblower, provisions of the False Claims Act. The qui tam case is captioned United States ex rel. Singletary, et al. v. Harmony Care Hospice, Inc., et al. , Case No. 2:10-cv-01404-PMD (D.S.C.).

Hospices provide palliative care – medical treatment that concentrates on reducing the severity of a disease’s symptoms – to patients who decide to forego curative care of their illness. Medicare beneficiaries are entitled to hospice care if they have a terminal prognosis of six months or less. The United States alleged that Harmony and Burton knowingly submitted or caused to be submitted false claims for patients who did not have such a prognosis and thus were not eligible for hospice care.

Under the Harmony settlement agreement, its owner and chief executive officer, Burton is individually liable for $200,000 of the settlement amount. The balance of more than $1 million will be paid by Harmony. As part of the settlement, Harmony and Burton will enter into a Corporate Integrity Agreement with the Office of Inspector General (OIG), Department of Health and Human Services (HHS), to address the allegations raised in the qui tam complaint. Together, Singletary and Fulton will receive $244,529.87 as their share of the government’s recovery.

Whistleblowers Key Prosecutorial Tool

The approximately $2 million paid out to whistleblowers under these two settlements drives home the growing importance that current or former employees, officers or other insiders increasingly play in federal and state health care fraud prosecutions. Whistleblowers like Ferrare, Singletary and Fulton are increasingly common and valuable tools that the federal government uses to find and prosecute alleged health care fraud. By promoting the availability of qui tam and other recoveries and broadly advertising their payment, federal prosecutors and investigators are priming the pump for future investigations and prosecution. See also Nextcare Inc. $10 Million False Claims Act Settlement Shows Qui Tam Role In False Claims Act Prosecutions; Oklahoma’s Harmon Memorial Hospital, Physician Pay $1.5M Qui Tam Health Care Fraud Settlement.

The two settlements also show the growing zealousness of the federal war on health care fraud. Both cases were investigated by the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009.

The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $10.1 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $13.9 billion. Federal officials have and continue to rack up an ever-increasing list of civil settlements and judgments using the False Claims Act and other civil enforcement tools. See e.g., See, e.g., Feds Health Fraud Suit Against Psychiatrists Shows Risks Providers Run From Aggressive Referral or Billing Activities; Recent OIG Audit Reports Provide Insights Where Fraud Audits Likely To Look Next; Hospital Chain HCA Inc. Pays $16.5 Million to Settle False Claims Act Allegations That Hospital; Pharmas Face New Pressure To Put Patients Before Profits After GlaxoSmithKline Record $3 Billion Health Care Fraud, FDCA Conviction & Settlement.

In addition to the high dollar civil judgments and settlements recovered. by the HEAT Task Force, federal prosecutors also are racking up a growing list of criminal convictions and sentences. See e.g., Health Care Providers Warned To Raise Defenses As Feds Charge 91 Individuals Bilked Medicare For Approximately $430 Million; Detroit-Area Doctor Charged for Role in Alleged $40 Million Medicare Fraud Scheme; Five More Individuals Charged in Detroit for Alleged Roles in $24.7 Million Medicare Fraud Scheme; Baton Rouge Area Women Heading To Prison For DME Health Care Fraud Participation; Houston Man Gets 24 Month Prison Sentence For Anti-Kickback & Other Health Care Fraud Convictions.

For instance, along with the Morton Plan and Harmony civil settlements, the Justice Department also announced on November 20, 2012 that a registered nurse pleaded guilty November 20 and a former program coordinator pleaded guilty November 19 for their roles in a $63 million mental health care fraud scheme involving defunct health provider Health Care Solutions Network Inc. (HCSN) in Miami. See here.

These and other investigations and enforcement actions show that health care providers, their owners, officers, providers and other staff need to take seriously health care reimbursement, referral and other health care fraud and compliance responsibilities, as well as to carefully manage workforces to mitigate exposures to qui tam and other health care fraud exposures.

These activities are intended to send a strong message to health care providers that bill Medicare, Medicaid, or other public or private health care programs that they must be prepared to defend any charges billed to these or other federal health care programs and to defend their other business practices.

Providers Urged To Manage Risks

In response to these threats, health care providers should take steps to strengthen their billing, referral, audit, medical and other recordkeeping and other compliance and risk management practices to enhance their ability to defend or prevent these exposures. While most providers already are moving to tighten these practices, the move to electronic health records, changing rules and other pressures are undermining the sufficiency of these efforts. This investigation shows that beyond mere aggressive billing practices, federal officials also are targeting for enforcement physicians and other health care providers that participate in financial or other referral incentive or reward practices prohibited by the anti-kickback, STARK or other relevant law as well as the filing of Medicare, Medicaid or other health claims for undelivered, unnecessary or otherwise uncovered care or services.

Amid these and other enforcement actions, all health industry players should exercise care to steer clear of activities that might violate federal health care fraud rules as well as consider whether corrective or other action might be necessary to address risks of prior activities that with the benefit of hindsight taking into account the current enforcement climate reflect potential exposures. Providers should carefully monitor existing Medicare, Medicaid and other federal and state program reimbursement, terms of participation, reimbursement and other guidance; Office of Inspector General (OIG), Justice Department and other agency audit and enforcement activities and other developments that could impact on the defensibility of their billing, referral or other practices and tighten compliance and oversight as necessary to mitigate risks.

In the case of physicians and certain other professionals, these plans need to include both efforts to manage potential government investigation risks and management of their practices to mitigate peer review or other disciplinary or practice regulatory oversight that often arises when the practices and hospitals start tightening oversight and controls on practices as part of their own efforts to protect their organizations from fraud or other audits.

While almost all health care providers can find room to improve their documentation and tighten other compliance, it also is important that providers also plan for how they will finance the cost of defending an audit or other investigation. Often, the financial cost of defending these and other charges prevents physicians or other health care providers from lodging effective defenses of legitimate practices. To help avoid this quagmire, providers generally will want to explore getting special liability coverage, indemnification or other protection as part of their planning arrangements.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish, audit, administer and defend billing, referral, privacy, staffing and recruitment and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Feds Health Fraud Suit Against Psychiatrists Shows Risks Providers Run From Aggressive Referral or Billing Activities

November 16, 2012

A civil lawsuit seeking millions of dollars of damages from a Chicago-area psychiatrist provides a clear warning to physicians and other health care providers of the significant potential legal risks that can arise if they improperly receive compensation or other perks for participating in conferences, prescribing treatments or engage in other arrangements that violate federal or state anti-kickback or other health care fraud laws.On November 15, 2012, the Justice Department sued Chicago-area psychiatrist Dr. Michael J. Reinstein in the Northern District of Illinois with receiving illegal kickbacks on at least 50,000 claims and filing at least 140,000 false Medicare and Medicare Claims for antipsychotic medications he prescribed for thousands of mentally ill patients in area nursing homes. The suit against Dr. Michael J. Reinstein seeking triple damages under the False Claims Act, plus a civil penalty of $5,500 to $11,000 for each alleged false claim. See here.

The lawsuit involves Reinstein’s use of clozapine, a rarely-used medication that has serious potential side effects and is generally considered a drug of last resort, particularly for elderly patients. While clozapine has been shown to be effective for treatment-resistant forms of schizophrenia, it is also known to cause numerous side effects, including a potentially deadly decrease in white blood cells, seizures, inflamation of the heart muscle, and increased mortality in elderly patients.

According to the suit, 69-year old Reinstein has provided psychiatric medical services in the Chicago area since 1973. According to the lawsuit, Reinstein routinely prescribed antipsychotic and other psychiatric medications knowing that, because most of his patients are indigent nursing home residents, pharmacies dispensing the medications submitted claims to Medicaid, and beginning in 2006, to Medicare Part D. Reinstein also submitted Medicare and Medicaid claims for pharmacologic management of his patients, knowing that he did not engage in substantive evaluations of his patients’ medical and psychiatric conditions to properly manage their medications. Instead, he allegedly prescribed medications to his patients based on his receipt of kickbacks from pharmaceutical companies.

Prior to August 2003, Reinstein prescribed Clozaril, the trade name for clozapine manufactured by Novartis, and he often had more than 1,000 patients using the medication at any given time. For many years, Novartis paid Reinstein to promote Clozaril, the complaint alleges. After Novartis’ patent for Clozaril expired in 1998, Reinstein resisted pharmacy and drug company efforts to switch his patients to generic clozapine and he continued to be the largest prescriber of Clozaril to Medicaid recipients in the United States. In July 2003, Novartis notified Reinstein that was withdrawing its support for Clozaril, and ended the regular payments that it had been making to Reinstein.

In August 2003, Reinstein finally agreed to switch his patients to generic clozapine manufactured by Miami-based IVAX Pharmaceuticals, Inc., the suit alleges, if IVAX agreed to pay Reinstein $50,000 under a one-year “consulting agreement;” pay his nurse to speak on behalf of clozapine; and fund a clozapine research study by a Reinstein-affiliated entity known as Uptown Research Institute. IVAX agreed and Reinstein immediately began switching his patients from Clozaril to IVAX’s clozapine. He quickly became the largest prescriber of generic clozapine in the country.

“Reinstein’s inordinate prescribing of clozapine stands in stark contrast to its extremely limited use by other physicians,” the lawsuit states. While generally only four percent of schizophrenia patients who were prescribed antipsychotics received clozapine, during the time Reinstein was alegedly accepting kickbacks from IVAX, more than 50 percent of his patients were prescribed IVAX’s clozapine. At one nursing home, Reinstein had 75 percent of the 400 residents on IVAX’s clozapine.

Between 2003 and 2006, the lawsuit charges Reinstein requested, and IVAX provided, additional direct and indirect benefits to Reinstein and his associates, including paying airfare, lodging, meals, and entertainment expenses for a pharmacy owner and spouse, Reinstein’s nurse, his accountant and spouse, his administrative assistant and spouse, and Reinstein and his wife to travel to IVAX’s headquarters in Miami. IVAX also paid for Reinstein and his entourage to go on a fishing trip, a boat cruise, and a golf outing; annual renewal of Reinstein’s $50,000 “consulting agreement;” and tickets to sporting events and free IVAX-manufactured medication for Reinstein’s personal use.

In January 2006, IVAX became a subsidiary of Teva Pharmaceuticals Industries, Ltd., an Israeli company. About seven months before the merger, Reinstein began moving large numbers of his patients to a form of clozapine manufactured by a competitor of IVAX/Teva. In April 2006, Teva paid all expenses for Reinstein and his entourage to travel to Miami, including a $2,300 boat cruise, and at least two dinners costing more than $1,700 each. During this trip Teva employees asked Reinstein what the company could do to induce Reinstein to prescribe more clozapine, and Reinstein suggested that Teva hire an associate of his from Chicago, the lawsuit alleges. Teva agreed and in the months after the hiring Reinstein put several hundred patients back on Teva’s clozapine. From 2007 to 2009, the suit alleges, Teva and Reinstein entered into annual “speaker agreements” that resulted in Teva paying Reinstein more than $100,000.

Based on this alleged conduct, the suit charges Medicaid received and paid more than 100,000 false claims from various pharmacies for IVAX/Teva clozapine prescriptions written by Reinstein between August 2003 and July 2011 as a result of illegal kickbacks he solicited and received from IVAX and Teva. Between 2006 and July 2011, Medicare Part D received and paid more than 40,000 false claims involving similar kickback-induced prescriptions. Likewise, between August 2003 and July 2011, Reinstein allegedly submitted more than 40,000 false claims and received payment from Medicaid for purported pharmacologic management, as well as more than 10,000 similar false claims to Medicare.

This lawsuit is one a growing list of civil and criminal investigations and enforcement actions by federal and state prosecutors targeting health care providers using expanded health care fraud laws and investigatory and prosecutorial powers granted under the Affordable Care Act and other legislation to help bring down health care costs.

Through these and other flashy prosecutions, as well as a continuous campaign of audits and other activities, federal officials are trying to reduce Medicare and other health care expenditures, both by prosecuting health care providers for intentionally submitting false claims, as well as using the treat of audits, program, disqualification or civil or criminal prosecution to scare health care providers to reduce legitimate billings that could trigger a federal audit or other federal scrutiny.

Federal officials are aided in these efforts by an arsenal of new health care fraud statistical profiling and other health care fraud detection and enforcement tools granted by Congress in recent years that make it easier for federal officials to target and successfully prosecute or bring other sanctions against health care providers whose billing or other business practices come under scrutiny.

Coupled with the ever-lengthening list of civil settlements and civil monetary penalties, program disqualifications, and audits, Federal officials use high profile criminal sweeps like those announced today both to send a message to health care providers generally, and as a tool to pressure and encourage health care providers to accept settlements proposed by federal auditors and prosecutors to avoid the potential threat of more serious criminal, civil or administrative prosecutions.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish, audit, administer and defend billing, referral, privacy, staffing and recruitment and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | DME, Doctor, Durable Medical Equipment, Hospital, Hospital, Inpatient Rehabilitation Facility, Medicaid, Medicare, OIG, Physician, Prescription Drugs, Real Estate, Reimbursement, Rural Health Care, Stark | Tagged: Anti-Kickback, DME, Health Care Fraud, healthcare provider, home health, Hospital, Physician, referral, STARK | Permalink
Posted by Cynthia Marcotte Stamer

Health Care Providers Warned To Raise Defenses As Feds Charge 91 Individuals Bilked Medicare For Approximately $430 Million

October 4, 2012

Health Care Providers Warned To Raise Defenses As Feds Charge 91 Individuals Bilked Medicare For Approximately $430 Million

A total of 91 doctors, nurses and other licensed medical professionals in Dallas, Houston, Los Angeles, Miami, Brooklyn, Baton Rouge and Chicago are facing health care fraud charges for their alleged participation in false Medicare billings totaling approximately $429.2 million to Medicare fraud schemes under federal indictments unsealed in a joint Department of Justice and HHS Medicare Fraud Strike Force nationwide takedown jointly announced by Attorney General Eric Holder, Health & Human Services (HHS) Secretary Kathleen Sebelius, and other agencies today (October 4, 2012). Coming on the heels of President Obama’s touting of the health care fraud fighting success of his Administration during his debate with Presidential Candidate Mitt Romney, the indictments are the latest warning to health care providers of the advisability of tightening their Medicare and other health care billing and other compliance practices.

Highlights of The Latest Strike Force Action

Together, dozens of charged individuals were arrested or surrendered as federal officials unsealed indictments charging more than $230 million in home health care fraud; more than $100 million in mental health care fraud and more than $49 million in ambulance transportation fraud; and millions more in other frauds.

The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided. In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided. Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $429.2 million in fraudulent billing.

“Today’s coordinated actions represent one of the largest Medicare fraud takedowns in Department of Justice history, as measured by the amount of alleged fraudulent billings,” said Assistant Attorney General Breuer. “We have made it one of the Department’s missions to hold accountable those who abuse the Medicare program for personal profit. And there are Medicare fraudsters in prisons across the country – some who will be there for decades – who can attest to our determination, and our effectiveness.”

In Miami, a total of 33 defendants are charged for their alleged participation in various fraud schemes involving a total of $204.5 million in false billings for home health care, mental health services, occupational and physical therapy, and DME. In one case, three defendants are charged for participating in a fraud scheme at LTC Professional Consultants and Professional Home Care Solutions Inc. which led to approximately $74 million in fraudulent billing for home health care. In another case, five defendants are charged for participating in a fraud scheme at Hollywood Pavilion which led to $67 million in fraudulent billing for mental health services.

Sixteen individuals, including three doctors and one licensed physical therapist, are charged in Los Angeles with participating in various fraud schemes involving a total of $53.8 million in false billings. In one case, four defendants are charged for allegedly participating in a fraud scheme at Alpha Ambulance Inc., which led to approximately $49.2 million in fraudulent billing for ambulance transportation. The case represents the largest ambulance fraud scheme ever prosecuted by the Medicare Fraud Strike Force. According to court documents, the defendants provided beneficiaries ambulance rides that were medically unnecessary.

In Dallas, 14 individuals – including two doctors and two registered nurses – are charged for their alleged participation in various fraud schemes involving a total of $103.3 million in false billings. In one case, three defendants – a medical doctor and two registered nurses – are charged with participating in a fraud scheme at Raphem Medical Practice and PTM Healthcare Services which led to approximately $100 million in fraudulent billing for home health care services. According to court documents, Dr. Joseph Megwa signed approximately 33,000 prescriptions for more than 2,000 unique Medicare beneficiaries from 2006 to 2011. Many of these Medicare beneficiaries had primary care physicians who never certified home healthcare services for them. In order to handle the volume of prescriptions, Megwa allegedly signed stacks of documents without reviewing them.

Seven individuals are charged in Houston for their participation in a fraud scheme at a hospital which led to $158 million in fraudulent billing for community mental health center services. According to court documents, the defendants who served as administrators at the hospital paid kickbacks – in the form of cigarettes, food and coupons redeemable for items available at the hospital’s “country stores” – to Medicare beneficiaries in exchange for those beneficiaries’ attendance at the hospital’s partial hospitalization programs (PHP). Allegedly, beneficiaries watched television, played games and engaged in other non-PHP activities rather than receiving the services for which the hospital billed Medicare. Previously, on Feb. 22, 2012, the assistant administrator of the hospital, Mohammad Kahn, pleaded guilty to conspiracy to commit health care fraud and paying kickbacks related to $116 million worth of fraudulent claims submitted to Medicare. After his guilty plea, an additional $42 million in fraudulent claims were discovered that are included in today’s totals.

In Brooklyn, 15 individuals, including one doctor and four chiropractors, are charged for their alleged participation in various fraud schemes involving a total of $23.2 million in false billings. In one case, nine defendants, including a medical doctor, are charged with participating in a fraud scheme at Cropsey Medical Care PLLC which led to approximately $13.8 million in fraudulent billing for physical therapy and related services. According to court documents, the defendants paid cash kickbacks to Medicare beneficiaries in exchange for physical therapy that was not medically necessary and on some occasions never provided to beneficiaries.

In Baton Rouge, four defendants, including a licensed practical nurse, are charged for their roles in fraud schemes involving approximately $2.4 million in false claims for medically unnecessary durable medical equipment.

In Chicago, two defendants, including a dermatologist and a psychologist, are charged for their roles in fraud schemes involving, according to court documents, millions of dollars in false claims for medically unnecessary laser treatments and psychotherapy services.

In addition to the criminal indictments, HHS also used recently expanded health care fraud powers granted as part of the Affordable Care Act to suspend and took other administrative action against 30 health care providers following a data-driven analysis that HHS claims showed “credible allegations of fraud.” Under the Affordable Care Act, HHS is able to suspend payments until the resolution of an investigation.

According to today’s announcement the charges and other actions announced today resulted from coordinated health care fraud investigations conducted by the Medicare Fraud Strike Force as part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Federal officials now credit strike force operations in nine locations have charged more than 1,480 defendants who collectively have falsely billed the Medicare program for more than $4.8 billion since strike force operations began in March 2007.

Charges Part of Widening War Against Health Care Providers

The charges unsealed today are the latest and among the most sweeping of an ever-lengthening list of flashy prosecutions and federal program disqualification actions that federal officials are conducting against health care providers using expanded health care fraud laws and investigatory and prosecutorial powers granted under the Affordable Care Act and other legislation.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish, audit, administer and defend billing, referral, privacy, staffing and recruitment and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | DME, Doctor, Durable Medical Equipment, Hospital, Hospital, Inpatient Rehabilitation Facility, Medicaid, Medicare, OIG, Physician, Prescription Drugs, Real Estate, Reimbursement, Rural Health Care, Stark | Tagged: Anti-Kickback, DME, Health Care Fraud, healthcare provider, home health, Hospital, Physician, referral, STARK | Permalink
Posted by Cynthia Marcotte Stamer

Recent OIG Audit Reports Provide Insights Where Fraud Audits Likely To Look Next

September 24, 2012

Healthcare providers, Medicare, Medicaid, Children’s Health Insurance Program (CHIP) intermediaries, State Medicaid and CHIP fund recipients, Medicare and Medicaid Advantage Plan and others wanting to get a leg up on potential audit targets likely to draw the attention of the Department of Health & Human Services (HHS) Office of Inspector General (OIG) and their health care fraud auditors and investigators may get valuable insights by monitoring OIG audit reports of Medicare Intermediaries and others. Reports of deficiencies uncovered in these audits and recommendations to tighten procedures and seek repayments often prompt demands for repayment and tighter payment and audit guidelines and procedures.

The following are some of the most recently-issued OIG audit reports:

New York Claimed Some Unallowable Costs for Services by New York City Providers under the State’s Developmental Disabilities Waiver Program (A-02-10-01027)

OIG says the New York State Department of Health (DOH) claimed Federal Medicaid reimbursement for some Office for People With Developmental Disabilities (OPWDD) waiver program services provided by New York City providers that did not comply with certain Federal and State requirements. http://go.usa.gov/rk8V.

Based on sample results, OIG estimates that DOH improperly claimed $7.8 million in Federal Medicaid reimbursement for OPWDD waiver program services during calendar years 2006 through 2008. Federal law authorizes Medicaid home and community-based services (HCBS) waiver programs. A State’s HCBS waiver program must be approved by CMS and allows a State to claim Federal reimbursement for services not usually covered by Medicaid.

Of the 100 beneficiary-months in the random sample, DOH properly claimed Medicaid reimbursement for OPWDD waiver program services during 86 beneficiary-months. However, DOH claimed Medicaid reimbursement for services that did not comply with certain Federal and State requirements for the remaining 14 beneficiary-months. OIG reported the claims for unallowable services were made because DOH and OPWDD’s policies and procedures for overseeing and administering the waiver program were not adequate to ensure that (1) providers claimed reimbursement only for services actually provided and maintained all the required documentation to support services billed and (2) OPWDD waiver program services were provided only to beneficiaries pursuant to written plans of care.

OIG recommended that DOH:

Refund $7.8 million to the Federal Government and
Work with OPWDD to strengthen policies and procedures to ensure that (a) providers claim reimbursement only for OPWDD waiver program services actually provided and maintain the required documentation to support services billed and (b) OPWDD waiver program services are provided pursuant to written plans of care.

DOH and OPWDD concurred with the recommendations.

Medicare Contractors’ Payments to Providers in Jurisdiction 11 for Full Vials of Herceptin Were Often Incorrect (A-03-11-00013)

OIG reported that most payments for one or more full vials of Herceptin that the Medicare contractors made to providers in Jurisdiction 11 (North Carolina, South Carolina, Virginia, and West Virginia) from January 2008 through December 2010 were incorrect. Herceptin (trastuzumab) is a Medicare-covered biological drug used to treat breast cancer that has spread to other parts of the body. http://go.usa.gov/rk9P.

Of the 2,507 selected line items, OIG says 2,029 were incorrect and included overpayments totaling $2.4 million that the providers had not identified or refunded by the beginning of our audit. Providers refunded overpayments on 138 line items totaling $131,000 before our fieldwork. The remaining 340 line items were correct.

The 2,029 incorrect line items included incorrect units of service and a lack of supporting documentation. The providers attributed the incorrect payments to chargemaster errors, clerical errors, and billing systems that could not prevent or detect the incorrect billing of units of service. In some cases, providers could not store unused doses for later use because their pharmacies incorrectly reconstituted the Herceptin. When this occurred, the providers billed Medicare for the entire vial, including waste. The Medicare contractors made these incorrect payments because neither the Fiscal Intermediary Standard System nor the Common Working File had sufficient edits in place during our audit period to prevent or detect the overpayments.

OIG recommended that Palmetto GBA, LLC (Palmetto), the Medicare Administrative Contractor for Jurisdiction 11:

(1) Recover the $2.4 million in identified overpayments,
Implement a system edit that identifies for review line items for multiuse-vial drugs with units of service equivalent to one or more entire vials, and
Use the results of this audit in its provider education activities.

Palmetto concurred with the OIG findings and recommendations and described corrective actions that it had taken or planned to take.

Texas Did Not Report Excess Contractor Profits in Accordance With Federal Regulations (A-06-10-00062)

A Medicaid Management Information System (MMIS) is a system of software and hardware used to process Medicaid claims and manage information about Medicaid beneficiaries, services, and providers. The Texas Health and Human Services Commission (State agency) contracts with a fiscal agent, Affiliated Computer Services/Texas Medicaid Health Partnership (ACS/TMHP), to process claims through the MMIS. The contract between the State agency and ACS/TMHP requires a prospective price redetermination (PPR) audit to establish whether ACS/TMHP earned profit in excess of the 11 percent allowed by the contract.

OIG reports it found that the State agency did not refund $2.6 million (Federal share) of the $26.7 million in excess profits identified through the PPR audit in accordance with Federal requirements. During fiscal year 2009, the State agency claimed expenditures for 20 MMIS projects with total costs of $71.3 million. All of these expenditures were allowable and claimed at the appropriate reimbursement rate; however, the State agency did not obtain prior approval for 2 of the 20 projects. Also, the State agency did not obtain prior approval for 16 additional projects. The total budgets for the 18 projects for which the State agency did not obtain prior approval totaled $59 million ($32.9 million Federal share). http://go.usa.gov/rkXW.

OIG recommended that the State agency:

(1) Refund to the Federal Government $2.6 million for excess profits related to the PPR audit,
Ensure that prior approval is obtained on future projects as required by Federal regulations, and
Obtain retroactive approval for the 18 projects that did not have the required prior approval from the Centers for Medicare & Medicaid Services (CMS).

The State agency agreed with OIG’s first and third recommendations and described corrective actions it had taken or planned to take. Regarding the second recommendation, the State agency described the process by which it seeks CMS approval for certain projects.

Review of Medicare Outpatient Billing for Selected Drugs at Self Regional Healthcare (A-09-12-02032)

For the 61 line items reviewed, OIG reported that Self Regional Healthcare did not bill Medicare for injections of selected drugs in accordance with Federal requirements, resulting in overpayments totaling $130,000. http://go.usa.gov/rkX.d.

Review of Medicare Outpatient Billing for Selected Drugs at Methodist Healthcare – Memphis Hospitals (A-09-12-02022)

For 60 of the 82 line items reviewed, OIG reported it found that Methodist Healthcare – Memphis Hospitals did not bill Medicare for injections of selected drugs in accordance with Federal requirements, resulting in overpayments totaling $178,000. http://go.usa.gov/rkNY.

Medicare Part D Made Some Incorrect Payments to Community Insurance Inc. for Institutional Beneficiaries in 2008 (A-05-11-00042)

OIG reports that the Medicare Part D program incurred drug costs for Medicare Advantage beneficiaries during Skilled Nursing stays that should have been covered under Part C in 2008. Community Insurance Inc’s incurrence of the $23,000 in gross drug costs as Part D costs had an overpayment effect of $13,000 as well as a $9,000 reconciliation effect at year end. http://go.usa.gov/rkNB.

North Shore Community Health, Inc., Claimed Unallowable Costs Against Recovery Act Grants (A-01-11-01502)

OIG reported it could not determine whether $2 million in American Recovery and Reinvestment Act of 2009 (Recovery Act) grant costs claimed by North Shore Community Health, Inc. (North Shore), was allowable under the terms of the grants and applicable Federal regulations. North Shore did not track and account for Recovery Act expenditures separately from other (Federal and non-Federal) operating expenses; therefore, it could not demonstrate that it spent Recovery Act grant funds for allowable costs. http://go.usa.gov/rk85.

OIG says this deficiency occurred because North Shore did not:

(1) Maintain a financial management system that provided for accurate, current, and complete disclosure of the financial results of its Recovery Act grants and
Separately track and account for Recovery Act funds.

OIG recommended that the Health Resources and Services Administration (HRSA) require North Shore to refund $2 million to the Federal Government, or work with North Shore to determine whether any of the costs that it claimed against Recovery Act grants were allowable, and ensure North Shore:

(1) Develops a financial system that provides for the accurate, current, and complete disclosure of the financial results of each HHS-sponsored project or program and
Tracks and accounts for each grant’s expenditures separately from other operating expenditures.

North Shore stated that it adjusted its internal financial reporting process to be in compliance with Federal requirements.

Under the Recovery Act, P.L. No. 111-5, enacted February 17, 2009, HRSA received $2.5 billion, including $2 billion to expand the Health Center Program to serve more patients, stimulate new jobs, and meet the expected increase in demand for primary health care services among the Nation’s uninsured and underserved populations.

OIG Says Lawndale Christian Health Center Claimed Unallowable Costs Under Recovery Act Grants (A-05-11-00057)

Lawndale Christian Health Center claimed $535,000 that was allowable under the terms of the grant and applicable Federal regulations. However, Lawndale claimed Federal grant expenditures totaling $174,000 that were unallowable. We could not determine the allowability of costs totaling $637,000 according to the OIG. See http://go.usa.gov/rFQP.

Alabama Improperly Claimed Federal Funds for Children’s Health Insurance Program Enrollees Who Had Medicaid or Other Health Insurance Coverage (A-04-11-08008)

OIG reports that Alabama improperly claimed Children’s Health Insurance Program (CHIP) Federal financial participation (FFP) for some individuals who were concurrently enrolled in CHIP and Medicaid. The Federal and State Governments jointly fund and administer both Medicaid and CHIP. States may not claim CHIP FFP for individuals who are concurrently enrolled in CHIP and Medicaid or who have other health insurance coverage. See http://go.usa.gov/rFQG.

Based on OIG sample results, OIG estimated that Alabama improperly claimed $1.5 million in CHIP FFP for enrollees who were concurrently enrolled in CHIP and Medicaid from October 1, 2009, through September 30, 2010. Alabama also improperly claimed $153,000 in CHIP FFP for individuals who had other health insurance coverage from October 1, 2009, through September 30, 2010.

OIG says the concurrent enrollment in CHIP and Medicaid occurred because:

Medicaid enrollment could be retroactive for up to 3 months, during which the individual could also have been enrolled in CHIP and
Supplemental Security Income eligibility, and consequent Medicaid enrollment, could be retroactive to the original application date, a period during which the individual could also have been enrolled in CHIP.

Moreover, the State agency did not have adequate internal controls to prevent or promptly correct concurrent enrollments. The CHIP payments that Alabama claimed on behalf of individuals who had other health insurance coverage occurred because State policy allowed for a coordination of benefits between CHIP and other health insurance coverage.

OIG recommended that Alabama:

Refund $1.5 million (Federal share) for FFP claimed on behalf of individuals who were concurrently enrolled in CHIP and Medicaid,
Refund $153,000 (Federal share) for FFP claimed on behalf of individuals enrolled in CHIP who had other health insurance coverage,
Develop additional policies and procedures to prevent or promptly recoup CHIP payments made on behalf of individuals who are identified as enrolled concurrently in Medicaid, and
Revise the current policy that allows for a coordination of benefits between CHIP and other health insurance coverage.

The OIG notes Alabama disagreed with all of its recommendations.

South Carolina Claimed Some Unallowable Room-and-Board Costs under the Intellectual and Related Disabilities Waiver (A-04-11-04012)

OIG reports that the South Carolina Department of Health & Human Services (State agency) operates a waiver program that provides long-term care and support for individuals with intellectual or related disabilities. The State agency contracts with the South Carolina Department of Disabilities and Special Needs (the Department) to provide waiver services. The Department provides these services through contractual arrangements with a network of 39 local Disabilities and Special Needs (DSN) Boards.

OIG reported it found that the State agency claimed Medicaid reimbursement of $6.7 million ($4.8 million Federal share) for unallowable room-and-board costs under the waiver program that the Department operated. The State agency claimed unallowable room-and-board costs because neither the State agency nor the Department had adequate controls to:

Ensure that the Department followed applicable Federal law and guidance or its own guidance or
Detect errors or misstatements on the local DSN boards’ cost reports. See http://go.usa.gov/rFQz.

Additionally, OIG says the Department did not prescribe a uniform format for the local DSN boards to follow when preparing the cost reports. Rather, each local board prepared its cost reports in its own format, making it difficult to identify when unallowable costs were claimed.

OIG recommended that the State agency:

Refund to the Federal Government $4.8 million, representing the Federal share of the room-and-board costs that the Department improperly claimed on its waiver cost reports;
Instruct the Department to follow Federal law and its own guidance and remove room-and-board related administrative and general costs from future waiver program cost reports;
Instruct the Department to develop a uniform cost reporting process and require each local board to follow this process;
Instruct the Department to strengthen its cost report review procedures to ensure that it will detect errors or misstatements on the local DSN boards’ cost reports; and
Strengthen its own procedures for reviewing the waiver cost reports submitted by the Department.

The State agency concurred with all of our recommendations and said that it would work with CMS to negotiate repayment of the improperly claimed room-and-board costs.

Review of New Mexico Medicaid Personal Care Services Provided by Coordinated Home Health (A-06-09-00064)

The OIG reported that its audit found that the State did not always ensure that Coordinated Home Health’s (Coordinated) claims for Medicaid personal care services complied with certain Federal and State requirements. Based on sample results, OIG estimated that Coordinated improperly claimed at least $11 million (Federal share) for personal care services during the period October 1, 2006, through September 30, 2008. http://go.usa.gov/rFUW.

According to OIG, personal care services may be provided to individuals who are not inpatients at a hospital or residents of a nursing facility, an intermediate care facility for individuals with intellectual disabilities, or an institution for mental disease. Examples of personal care services include, but are not limited to, cleaning, shopping, grooming, and bathing.

Of the 100 claims in the OIG sample, OIG reported that 54 complied with requirements, but 46 did not. Three of the forty-six claims were partially allowable. The 46 claims contained a total of 60 deficiencies: 49 deficiencies on insufficient attendant qualifications and 11 deficiencies on other concluded that Coordinated improperly claimed $8,000 for the 46 claims.

Based on these findings, OIG recommended that the State:
Refund to the Federal Government the $11 million paid to Coordinated for unallowable personal care services and
Ensure that personal care services providers maintain evidence that they comply with Federal and State requirements.

OIG reported that Coordinated disagreed with almost all of OIG’sfindings, and the State disagreed with OIG’s recommended refund amount. The State also said that some of the documentation requirements are not Federal requirements; they are State requirements, which do not require recovery of payments.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

Hospital Chain HCA Inc. Pays $16.5 Million to Settle False Claims Act Allegations That Hospital

September 23, 2012

HCA Inc., one of the nation’s largest for-profit hospital chains, has agreed to pay the United States and the state of Tennessee $16.5 million to settle claims that it violated the False Claims Act and the Stark Statute, the Department of Justice announced September 19, 2012. The settlement agreement and the litigation it resolves are a reminder to hospitals, physicians and other health care providers of the growing readiness of the Justice Department and other federal and state regulators and enforcement agencies to prosecute health care providers for STARK, anti-kickback back or other violations of federal or state health health care fraud laws.

HCA Settlement & Underlying Charges

As alleged in the settlement agreement, during 2007, HCA, through its subsidiaries Parkridge Medical Center, located in Chattanooga, Tenn., and HCA Physician Services (HCAPS), headquartered in Nashville, Tenn., entered into a series of financial transactions with a physician group, Diagnostic Associates of Chattanooga, through which it provided financial benefits intended to induce the physician members of Diagnostic to refer patients to HCA facilities. These financial transactions included rental payments for office space leased from Diagnostic at a rate well in excess of fair market value in order to assist Diagnostic members to meet their mortgage obligations and a release of Diagnostic members from a separate lease obligation.

The Stark Statute restricts financial relationships that hospitals may enter into with physicians who potentially may refer patients to them. Federal law prohibits the payment of medical claims that result from such prohibited relationships.

The civil settlement resolves a lawsuit, United States ex rel. Bingham v. HCA, No. 1:08-CV-71 (E.D. Tenn.), pending in federal court in the Eastern District of Tennessee under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens to bring civil actions on behalf of the United States and share in any recovery. As part of the civil settlement, HCA has agreed to pay $16.5 million to the United States and the state of Tennessee, with the federal portion representing $15,693,000 of the settlement amount. The whistleblower will receive an 18.5 percent share.

Also as part of the settlement, Parkridge Medical Center has entered into a comprehensive five-year Corporate Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services to ensure its continued compliance with federal health care benefit program requirements.

Settlement Part of Expanding Health Care Fraud Prosecution Efforts

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $9.4 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $13.1 billion.

In announcing the resolution agreement, federal officials emphasized their readiness to prosecute STARK, anti-kickback and other health care fraud statutes.

“The Department of Justice continues to pursue cases involving improper financial relationships between health care providers and their referral sources, because such relationships can corrupt a physician’s judgment about the patient’s true healthcare needs,” said Stuart F. Delery, the Acting Assistant Attorney General for the Department of Justice’s Civil Division.

“Physicians should make decisions regarding referrals to health care facilities based on what is in the best interest of patients without being induced by payments from hospitals competing for their business,” said Bill Killian, U.S. Attorney for the Eastern District of Tennessee.

“ Improper business deals between hospitals and physicians jeopardize both patient care and federal program dollars,” said Daniel R. Levinson, Inspector General of the Department of Health and Human Services. “Our investigators continue to work shoulder to shoulder with other law enforcement authorities to stop schemes that imperil scarce health care resources.”

Coupled with the ever-lengthening list of civil settlements like the HCA settlement, and civil monetary penalties, program disqualifications, and criminal prosecutions, these announcements send a strong message to health care providers to review their transactions, referral and other relationships, and billing practices and address potential exposures.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Detroit-Area Doctor Charged for Role in Alleged $40 Million Medicare Fraud Scheme

September 23, 2012

A Detroit-area doctor was charged and arrested on September 20, 2012 in the Eastern District of Michigan for his alleged leading role in a $40 million Medicare fraud scheme involving physician home visits and home health services. The Department of Justice (DOJ), the Department of Health and Human Services (HHS), the Federal Bureau of Investigations (FBI) and the HHS-Office of Inspector General (OIG) jointly announced the charges. In addition to the arrest, law enforcement agents executed search warrants at three locations and seizure warrants for three bank accounts related to the scheme.

According to a criminal complaint unsealed today in U.S. District Court in Detroit, Dr. Hicham Elhorr, 45, masterminded a $40 million scheme involving the submission of fraudulent claims submitted to Medicare for services that were medically unnecessary and/or never provided through House Calls Physicians (HCP), a physician home visiting service he owned and operated. Elhorr allegedly submitted claims through HCP for physician home visits for patients who were never seen and for visits conducted by doctors who were not licensed. The complaint alleges Elhorr submitted claims to Medicare for physician home visits purportedly rendered when he was out of the country, when beneficiaries were hospitalized or when the beneficiary was dead.

Elhorr is also alleged to have referred Medicare beneficiaries for medically unnecessary home health services, as well as accepted kickbacks from home health agencies in exchange for writing these referrals. According to court documents, since January 2008, HCP has billed Medicare for approximately $9.2 million. In the same time period, HCP has allegedly referred Medicare beneficiaries for home health services that have resulted in approximately $30.8 million of reimbursements from Medicare.

The case is being prosecuted by Trial Attorney Catherine K. Dick of the Criminal Division’s Fraud Section. The investigations were conducted jointly by the FBI and HHS-OIG, as part of the Medicare Fraud Strike Force, supervised by the U.S. Attorney’s Office for the Eastern District of Michigan and the Criminal Division’s Fraud Section.

Act To Manage Health Care Fraud Exposures

High profile criminal charges like this one tell only part of the story. While important and growing, the OIG and other civil audit and enforcement are targeting both health care providers that engage in overly aggressive billing and treatment practices while scaring legitimate providers into avoiding legitimate care and its billing in treatment areas subject to high audit and underbilling for fear of the costs and risks associated with drawing government scruitiny. Amid this quagmire, legitimate health care providers must carefully document their care and the underlying justification and manage their billing practices to mitigate fraud exposures while also ensuring that their care meets the requisite standards of care to meet professional standards of care. It’s a tough but critical task for which reimbursement is declining.

As health care fraud enforcement remains a lead Federal priority, health care providers face ever-heightening exposures to HEAT task force scrutiny and prosecution.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,330 defendants who have collectively billed the Medicare program for more than $4 billion.

Along with these criminal investigation and enforcement activities, health care providers also face civil monetary penalty, federal program disqualification and other civil and administrative remedies from billing, reimbursement and other health care fraud, billing audits and other enforcement and audit activities.

HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is stepping up audits, tightening pre-payment review, stepping up program disqualifications, and taking other steps to increase accountability and decrease the presence of fraudulent providers.

In response to these and other investigation and oversight activities, health care providers should strengthen their compliance practices and oversight and take other special care to position themselves and their billings to defend against possible challenge.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | Doctor, Health Care, Health Care Fraud, Health Care Provider, Medicaid, Medicare, Money Laundering, Physician | Tagged: Health Care, Health Care Fraud, Health Care Reimbursement, healtlh care provider, HEAT Task Force, Medicaid, Medicare, Physician | Permalink
Posted by Cynthia Marcotte Stamer

Five More Individuals Charged in Detroit for Alleged Roles in $24.7 Million Medicare Fraud Scheme

September 23, 2012

New Charges Bring To A Total of 9 Charged for Their Roles in the Scheme

Charges against five more individuals for their alleged participation in a $24.7 million Medicare fraud scheme involving purported home health and psychotherapy services were unsealed and made public in the Eastern District of Michigan on September 20, 2012 bring to a total of nine individuals now charged in the scheme.

The Department of Justice (DOJ), the Federal Bureau of Investigation (FBI) and the Department of Health and Human Services (HHS) jointly announced the charges.

DOJ charges in court documents that the scheme allegedly involved a total of more than $24.7 million in fraudulent claims submitted to Medicare for purported home health care and psychotherapy services that were medically unnecessary and/or never provided. Court documents allege that the defendants are operators, employees and marketers associated with home health care and psychotherapy clinics operating in and around Detroit. Defendants charged in the unsealed court documents unsealed today include: Mohammed Sadiq; Jamella Al-Jumail; Firas Alky; Clarence Cooper and Beverly Cooper.

Four defendants charged in the superseding indictment were previously charged and arrested in May 2012 for their roles in the scheme. Defendants previously charged include: Sachin Sharma, Dana Sharma, Abdul Malik Al-Jumail, and Felicar Williams.

The superseding indictment charges all defendants with one count of conspiracy to commit health care fraud; Sachin Sharma with five counts of health care fraud; Sachin Sharma, Abdul Malik Al-Jumail, Williams, Sadiq, Alky and Clarence Cooper with one count of conspiracy to pay and receive health care kickbacks; and Jamella Al-Jumail with one count of destruction of records in a federal investigation. The superseding indictment also seeks forfeiture from all defendants.

According to the superseding indictment, from January 2007 through April 2012, the defendants operated a large network of purported home health care and psychotherapy companies in the Detroit area through which they conspired to defraud Medicare.

According to court documents, Sachin Sharma, Dana Sharma, Abdul Malik Al-Jumail, Williams, Jamella Al-Jumail, Sadiq, Alky and other alleged co-conspirators incorporated home health care, psychotherapy and other medical service companies to carry out the scheme, including Reliance Home Care, LLC; First Choice Home Health Care Services Inc.; Associates in Home Care Inc.; Haven Adult Day Care Center LLC; Swift Home Care LLC; ABC Home Care Inc.; Accessible Home Care Inc.; and Be Well Home Care LLC. The defendants, along with co-conspirators, allegedly submitted Medicare enrollment applications to let these companies to bill Medicare. Sachin Sharma, Abdul Malik-Al-Jumail, Sadiq, Alky and others allegedly paid kickbacks and bribes to recruiters, including Williams and Clarence Cooper, to get Medicare beneficiaries’ information, which could be used to fraudulently bill Medicare for purported services provided by the companies they operated and controlled. The defendants then allegedly caused these companies to bill Medicare for home health and psychotherapy services, even though these services were not medically necessary and were often not provided.

According to the superseding indictment, the defendants caused Reliance, First Choice, Associates, Haven, Swift, ABC, Accessible and other home health, psychotherapy and medical services companies to bill approximately $24.7 million in claims to Medicare for services that were medically unnecessary and/or not provided. In addition, Jamella Al-Jumail is charged with destroying records relating to Accessible’s Medicare billings upon learning of the May 2012 arrest of Abdul Malik Al-Jumail, her co-conspirator and father.

Clarence and Beverly Cooper, Sadiq and Jamella Al-Jumail were arrested on September 21.

The case is being prosecuted by Fraud Section Assistant Chief Gejaa T. Gobena and Trial Attorney William G. Kanellis. The investigations were conducted jointly by the FBI and HHS-OIG, as part of the Medicare Fraud Strike Force, supervised by the U.S. Attorney’s Office for the Eastern District of Michigan and the Criminal Division’s Fraud Section.

Act To Manage Health Care Fraud Exposures

As health care fraud enforcement remains a lead Federal priority, health care providers face ever-heightening exposures to HEAT task force scrutiny and prosecution. Along with these criminal investigation and enforcement activities, health care providers also face civil monetary penalty, federal program disqualification and other civil and administrative remedies from billing, reimbursement and other health care fraud, billing audits and other enforcement and audit activities.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. Contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | DME, Doctor, false claims act, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Plan, Health Plans, Home Health, Hospital, Hospital, Medicaid, Medicare, Medicare Advantage, Money Laundering, OIG, Physician, Physician Licensing, Reimbursement | Tagged: false claims act, Health Care Fraud, HEAT, Medical Licensure, Physician, texas medical board | Permalink
Posted by Cynthia Marcotte Stamer

With Risks Rising, Listen To 9/19 OCR Webinar On Civil Rights Enforcement In Health Care

September 18, 2012

With the Department of Health & Human Services (HHS) Office of Civil Rights (OCR) and other federal agencies stepping up their civil rights and discrimination compliance audits and enforcement activities and private plaintiff discrimination suits against health care providers and other health industry organizations rising, health care, housing, health insurance and other organizations subject to these requirements are encouraged to learn more about HHS’ view and enforcement of these civil rights rules by participating in the webcast on “Addressing Health Disparities through Civil Rights Compliance and Enforcement” on Wednesday, September 19 from 3:00 p.m. to 4:30 p.m. eastern daylight savings time (EST).

September 19 Webinar

According to HHS, the September 19, 2012 webinar will be jointly hosted by the Health Resources and Services Administration Office of Equal Opportunity, Civil Rights & Diversity Management (OEOCRDM) Office of Federal Assistance Management (OFAM) and the HHS Office for Civil Rights (OCR) Office of the Assistant Secretary for Financial Resources (ASFR).

Topics of discussion will include:

How non-compliance can contribute to health disparities and disparities in quality care;
Opportunities to ensure HHS-funded programs are in compliance with civil rights laws;
How HHS OCR enforces compliance in your neighborhood.
A panel of OCR and ASFR experts answering questions

To join the webcast click here.

Rising Civil Rights Law Exposures Require Management

Public and private health care and housing providers may face discrimination exposures under various federal laws such as the public accommodation and other disability discrimination prohibitions of the ADA, Section 504, the Civil Rights Act and various other laws. Section 504 requires recipients of Medicare, Medicaid, HUD, Department of Education, welfare and most other federal assistance programs funds including health care, education, housing services providers, state and local governments to ensure that qualified individuals with disabilities have equal access to programs, services, or activities receiving federal financial assistance. The ADA extends the prohibition against disability discrimination to private providers and other businesses as well as state and local governments including but not limited to health care providers reimbursed by Medicare, Medicaid or various other federal programs The ADA requirements extend most federal disability discrimination prohibits to health care and other businesses even if they do not receive federal financial assistance to ensure that qualified individuals with disabilities have equal access to their programs, services or activities. In many instances, these federal discrimination laws both prohibit discrimination and require health care and other regulated businesses to put in place reasonable accommodations needed to ensure that their services are accessible and available to persons with disabilities. Meanwhile the Civil Rights Act and other laws prohibit discrimination based on national origin, race, sex, age, religion and various other grounds. These federal rules impact virtually all public and private health care providers as well as a broad range housing and related service providers.

As part of a broader emphasis on the enforcement of disability and other federal discrimination laws by the Obama Administration, OCR is making investigation and prosecution of suspected disability discrimination by health industry organizations a priority. OCR recently has announced several settlement agreements and issued letters of findings as part of its ongoing efforts to ensure compliance with Section 504 of the Rehabilitation Act of 1973 (Section 504) and the Americans with Disabilities Act of 1990 (ADA) as well as various other federal nondiscrimination and civil rights laws.

Defending or paying to settle a disability discrimination charge brought by a private plaintiff, OCR or another agency, or others tends to be financially, operationally and politically costly for a health care organization or public housing provider. In addition to the expanding readiness of OCR and other agencies to pursue investigations and enforcement of disability discrimination and other laws, the failure of health care organizations to effectively maintain processes to appropriately include and care for disabled other patients or constituents with special needs also can increase negligence exposure, undermine Joint Commission and other quality ratings, undermine efforts to qualify for public or private grant, partnerships or other similar arrangements, and create negative perceptions in the community.

As a result of its stepped up enforcement of the ADA, Section 504 and other civil rights and nondiscrimination rules, OCR is racking up an impressive list of settlements with health care providers, housing and other businesses for violating the ADA, Section 504 or other related civil rights rules enforced by OCR. While OCR continues to wage this enforcement battle in the programs it administers, the Departments of Justice, Housing & Urban Development (HUD), Education, Labor and other federal agencies also are waging war against what the Obama Administration perceives as illegal discrimination in other areas. Along side their own enforcement activities, OCR and other federal agencies are maintaining a vigorous public outreach to disabled and other individuals protected by federal disabilities and other civil rights laws intended to make them aware of and to encourage them to act to enforce these rights. To be prepared to defend against the resulting risk of claims and other enforcement actions created by these activities, health care, housing and other U.S. providers and businesses need to tighten compliance and risk management procedures and take other steps to prepare themselves to respond to potential charges and investigations.

Recent Settlements Highlight Risk

Within recent settlement agreements, entities agreed to take steps to come into compliance with Section 504 and ADA, including: review and revision of policies and procedures; training staff on their non-discrimination obligations; providing a grievance procedure for patients; and other corrective actions specific to each entity’s violations. To learn more details about these actions and settlements, see here.

These and other enforcement actions by OCR and other agencies demonstrate the significant increased federal emphasis on the enforcement of federal discrimination laws against private and public health care and housing providers, state and local governments and other businesses under the Obama Administration. In keeping with this renewed emphasis, the DCF settlement is the latest in a series of federal disability, national origin and other discrimination charges and settlements OCR, has brought over the past year against physicians, public and private hospitals, insurers, federally financed housing providers and other parties providing services financed under programs administered by OCR. As HUD, the Equal Employment Opportunity Commission (EEOC) and other federal agencies also similarly have increased emphasis in federal discrimination law enforcement during this period, health care providers and other federal program service providers need to be prepared to defend their programs and practices to withstand federal discrimination charges or other investigations by federal agencies, private plaintiffs or both.

As for employment discrimination, violators of these and other federal discrimination prohibitions applicable to the offering and delivery of services and products also face exposure to large civil damage awards to private plaintiffs as well as federal program disqualification, penalties and other federal agency enforcement. Unfortunately, while most businesses and governmental leaders generally are sensitive to the need to maintain effective compliance programs to prevent and redress employment discrimination, the awareness of the applicability and non-employment related disability and other discrimination risk management and compliance lags far behind.

Many private health care organizations assume that OCR’s enforcement actions are mostly a problem for state and local government agencies because state and local agencies and service providers frequently have been the target of OCR discrimination charges. However the record shows OCR enforcement risks are high for both public and private providers.

OCR can and does investigate and brings actions against a wide variety of public and private physicians, hospitals, insurers and other private health care and other federal program participants. In October, 2009, for instance, OCR announced that an Austin, Texas orthopedic surgeon whose practice group sees an average of 200 patients per week, had entered into a settlement agreement to resolve OCR charges that he violated Section 504 of the Rehabilitation Act by denying medically appropriate treatment from patients solely because they are HIV-positive.

Invest in Prevention To Minimize Liability Risks

In light of the expanding readiness of OCR to investigate and take action against health care providers for potential violations of the ADA, Section 504 and other federal discrimination and civil rights laws, health care organizations and their leaders should review and tighten their policies, practices, training, documentation, investigation, redress, discipline and other nondiscrimination policies and procedures. In carrying out these activities, organizations and their leaders should keep in mind the critical role of training and oversight of staff and contractors plays in promoting and maintaining required operational compliance with these requirements. Reported settlements reflect that the liability trigger often is discriminatory conduct by staff, contractors, or landlords in violation of both the law and the organization’s own policies.

To achieve and maintain the necessary operational compliance with these requirements, organizations should both adopt and policies against prohibited discrimination and take the necessary steps to institutionalize compliance with these policies by providing ongoing staff and vendor training and oversight, contracting for and monitoring vendor compliance and other actions. Organizations also should take advantage of opportunities to identify and resolve potential compliance concerns by revising patient and other processes and procedures to enhance the ability of the organization to learn about and redress potential charges without government intervention.

For More Information Or Assistance

If you need assistance reviewing or tightening your policies and procedures, conducting training or audits, responding to or defending an investigation or other enforcement action or with other health care related risk management, compliance, training, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to establish and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Health Care Orgs Disability Exposure High As $475K Paid To Settle Justice Department Charges Medical Fitness Screenings of EMTs, Others Violated ADA

August 13, 2012

The Justice Department’s announced prosecution and settlement of a disability discrimination lawsuit against Baltimore County, Maryland for allegedly violating the Americans With Disabilities Act (ADA) by screening emergency medical technicians (EMTs) and other public safety workers provides another reminder to health care providers and other public and private organizations of the need to strengthen their disability discrimination management practices to defend against rising exposures to actions by the U.S. Department of Justice, Department of Health & Human Services Office of Civil Rights (OCR), Equal Employment Opportunity Commission (EEOC) and other agencies as well as private law suits.

In the employment arena, a settlement announced August 7 with Baltimore County is particularly notable as part of this trend, both for its challenge of medical exams and inquiries for EMTs and others in health care and other areas where safety could be a concern, as well as its objection to medical inquiries made to workers on medical leave during the course of that leave.

Baltimore County Nailed For Health Screening of Public Safety Workers

Employment disability discrimination risk management clearly must be a key element of health care and other organization’s disability discrimination risk management and risk assessments should not take for granted the defensibility of practices previously assumed defensible as required by law or for health and safety reasons. Rather, health care and other employers that require employees to submit to medical examinations, question employees about physician or mental conditions or disabilities, or engage in other similar activities should check the defensibility of those practices in light of the growing challenges to these and other employee screening practices by the Obama Administration and private plaintiff attorneys like the Justice Department disability discrimination complaint that lead to a $475,000 settlement against Baltimore County, Maryland announced by the Justice Department on August 7, 2012. According to the Justice Department, Baltimore County, Maryland will pay $475,000 and change its hiring procedures to resolve a Justice Department lawsuit filed that charged the county violated the ADA by requiring employees to submit to medical examinations and disability-related inquiries without a proper reason, and by excluding applicants from EMT positions because of their diabetes.

ADA Employment Discrimination Generally

Title I of the ADA prohibits employers from discriminating against individuals on the basis of disability in various aspects of employment. The ADA’s provisions on disability-related inquiries and medical examinations show Congress’s intent to protect the rights of applicants and employees to be assessed on merit alone, while protecting the rights of employers to make sure that individuals in the workplace can efficiently do the essential functions of their jobs. An employer generally violates the ADA if it requires its employees to undergo medical examinations or submit to disability-related inquiries that are not related to how the employee performs his or her job duties, or if it requires its employees to disclose overbroad medical history or medical records. Title I of the ADA also generally requires employers to make reasonable accommodations to employees’ and applicants’ disabilities as long as this does not pose an undue hardship or the employer the employer otherwise proves employing a person with a disability with reasonable accommodation could not eliminate significant safety concerns. Employers generally bear the burden of proving these or other defenses. Employers are also prohibited from excluding individuals with disabilities unless they show that the exclusion is consistent with business necessity and they are prohibited from retaliating against employees for opposing practices contrary to the ADA. Violations of the ADA can expose businesses to substantial liability.

As reflected by the Baltimore County settlement, violations of the employment provisions of the ADA may be prosecuted by the EEOC or by private lawsuits and can result in significant judgments. Employees or applicants that can prove they were subjected to prohibited disability discrimination under the ADA generally can recover actual damages, attorneys’ fees, and up to $300,000 of exemplary damages (depending on the size of the employer).

Baltimore County Nailed For Medical Fitness Screening Of EMTs, Other Public Safety Workers

The U.S. Justice Department lawsuit against Baltimore County, Maryland is one in a growing series of lawsuits in which the Justice Department or Equal Employment Opportunity Commission (EEOC) is aggressively challenging medical examination and other medical screenings by private and public employers. In its lawsuit against the County, the Justice Department complaint identified 10 current and former police officers, firefighters, EMTs, civilian employees and applicants who were allegedly subjected to inappropriate and intrusive medical examinations and/or other disability-based discrimination. Justice Department officials claimed the County required some employees to undergo medical examinations or respond to medical inquiries that were unrelated to their ability to perform the functions of their jobs. The complaint also alleged the County required employees to submit to medical examinations that were improperly timed, such as requiring an employee who was on medical leave and undergoing medical treatment to submit to a medical exam even though the employee was not attempting to return to work yet.

According to the complaint, many affected employees – some of whom had worked for the County for decades – submitted to the improper medical exams for fear of discipline or termination if they refused. The complaint also alleges that the county retaliated against an employee who tried to caution against the unlawful medical exams and refused to hire two qualified applicants for EMT positions because they had diabetes.

In the proposed consent decree filed on August 7, 2012 and awaiting District Court approval, the County seeks to resolve the lawsuit by agreeing to:

Pay $475,000 to the complainants and provide more work-related benefits (including retirement benefits and back pay, plus interest);
Adopt new policies and procedures on the administration of medical examinations and inquiries;
Refrain from using the services of the medical examiner who conducted the overbroad medical examinations in question;
Stop the automatic exclusion of job applicants who have insulin-dependent diabetes mellitus; and
Provide training on the ADA to all current supervisory employees and all employees who participate in making personnel decisions.

Obama Administration Aggressively Enforcing & Interpreting Employment & Other Disability Discrimination Laws

The Baltimore County suit is reflective of the aggressive emphasis that the Obama Administration is placing on challenging employers that require employees to undergo medical screening, respond to medical inquiries or engage in other practices that the EEOC, Justice Department or other Obama Administration officials under Title I of the ADA, as well as its heavy emphasis upon enforcement of the ADA and other disability discrimination laws against U.S. businesses and state and local government agencies generally.

The Justice Department action against Baltimore County is part of the Obama Administration’s sweeping effort to enforce employment and other disability discrimination laws against businesses and state and local government agencies alike. While the Administration’s disability law enforcement reaches broadly, disability discrimination enforcement is particularly notable in the area of employment law. This enforcement targets both public employers like Baltimore County, and private employers. In the private employer arena, for instance, the EEOC earlier this year sued Wendy’s franchisee, CTW L.L.C., (Texas Wendy’s) for allegedly violating the ADA by denying employment to a hearing-impaired applicant. In its suit against Texas Wendy’s, the EEOC seeks injunctive relief, including the formulation of policies to prevent and correct disability discrimination as well as an award of lost wages and compensatory damages for Harrison and punitive damages against CTW L.L.C. In the suit, the EEOC charged that the general manager of a Killeen, Texas Wendy’s refused to hire Michael Harrison, Jr. for a cooker position, despite his qualifications and experience, upon learning that Harrison is hearing-impaired.

According to the EEOC, Harrison, who had previously worked for a different fast-food franchise for over two years, was denied hire by the general manager. Harrison said that after successfully interviewing with the Wendy’s shift manager, he attempted to complete the interview process by interviewing with Wendy’s general manager via Texas Relay, a telephonic system used by people with hearing impairments. Harrison’s told the EEOC that during the call he was told by the general manager that “there is really no place for someone we cannot communicate with.”

As illustrated by the suits against Baltimore County, Texas Wendy’s and many other public and private employers, employers must exercise care when making hiring, promotion or other employment related decisions relating to persons with hearing or other conditions that could qualify as a disability under the ADA.

Defending disability discrimination charges has become more complicated due to both the aggressive interpretation and enforcement of the ADA under the Obama Administration and amendments to the ADA that aid private plaintiffs, the EEOC, the Justice Department and others to prove their case. Provisions of the ADA Amendments Act (ADAAA) that expand the definition of “disability” under the ADA, signed into law on September 25, 2008, broadened the definition of “disability” for purposes of the disability discrimination prohibitions of the ADA to make it easier for an individual seeking protection under the ADA to establish that a person has a disability within the meaning of the ADA. The ADAAA retains the ADA’s basic definition of “disability” as an impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment. However, provisions of the ADAAA that took effect January 1, 2009 change the way that these statutory terms should be interpreted in several ways. Most significantly, the ADAAA:

Directs EEOC to revise that portion of its regulations defining the term “substantially limits;”
Expands the definition of “major life activities” by including two non-exhaustive lists: (1) The first list includes many activities that the EEOC has recognized (e.g., walking) as well as activities that EEOC has not specifically recognized (e.g., reading, bending, and communicating); and (2) The second list includes major bodily functions (e.g., “functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions”);
States that mitigating measures other than “ordinary eyeglasses or contact lenses” shall not be considered in assessing whether an individual has a disability;
Clarifies that an impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active;
Changes the definition of “regarded as” so that it no longer requires a showing that the employer perceived the individual to be substantially limited in a major life activity, and instead says that an applicant or employee is “regarded as” disabled if he or she is subject to an action prohibited by the ADA (e.g., failure to hire or termination) based on an impairment that is not transitory and minor; and
Provides that individuals covered only under the “regarded as” prong are not entitled to reasonable accommodation.

The ADAAA also emphasizes that the definition of disability should be construed in favor of broad coverage of individuals to the maximum extent permitted by the terms of the ADA and generally shall not require extensive analysis. In adopting these changes, Congress expressly sought to overrule existing employer-friendly judicial precedent construing the current provisions of the ADA and to require the EEOC to update its existing guidance to confirm with the ADAAA Amendments. Under the leadership of the Obama Administration, the EEOC and other federal agencies have embraced this charge and have significantly stepped up enforcement of the ADA and other federal discrimination laws.

The ADAAA amendments coupled with the Obama Administration’s emphasis on enforcement make it likely that businesses generally will face more disability claims from a broader range of employees and will possess fewer legal shields to defend themselves against these claims. These changes will make it easier for certain employees to qualify as disabled under the ADA. Consequently, businesses should act strategically to mitigate their ADA exposures in anticipation of these changes. Given the Obama Administration’s well-documented, self-touted activism of the EEOC, Justice Department and other federal agencies in prosecuting disability discrimination and promoting a pro-disability enforcement agenda, businesses are encouraged to review and tighten their employment disability discrimination compliance procedures and documentation.

Likewise, businesses should be prepared for the EEOC and the courts to treat a broader range of disabilities, including those much more limited in severity and life activity restriction, to qualify as disabling for purposes of the Act. Businesses should assume that a greater number of employees with such conditions are likely to seek to use the ADA as a basis for challenging hiring, promotion and other employment decisions. For this reason, businesses should exercise caution to carefully document legitimate business justification for their hiring, promotion and other employment related decisions about these and other individuals who might qualify as disabled taking into account both the broadened disability definition and the aggressive interpretative stance of the Obama Administration. Businesses also generally should tighten job performance and other employment recordkeeping to promote the ability to prove nondiscriminatory business justifications for the employment decisions made by the businesses.

Businesses also should consider tightening their documentation regarding their procedures and processes governing the collection and handling records and communications that may contain information regarding an applicant’s physical or mental impairment, such as medical absences, worker’s compensation claims, emergency information, or other records containing health status or condition related information. The ADA generally requires that these records be maintained in separate confidential files and disclosed only to individuals with a need to know under circumstances allowed by the ADA.

As part of this process, businesses also should carefully review their employment records, group health plan, family leave, disability accommodation, and other existing policies and practices to comply with, and manage exposure under the new genetic information nondiscrimination and privacy rules enacted as part of the Genetic Information and Nondiscrimination Act (GINA) signed into law by President Bush on May 21, 2008. Effective November 21, 2009, Title VII of GINA amends the Civil Rights Act to prohibit employment discrimination based on genetic information and restricts the ability of employers and their health plans to require, collect or retain certain genetic information. Under GINA, employers, employment agencies, labor organizations and joint labor-management committees face significant liability for violating the sweeping nondiscrimination and confidentiality requirements of GINA concerning their use, maintenance and disclosure of genetic information. Employees can sue for damages and other relief like currently available under Title VII of the Civil Rights Act of 1964 and other nondiscrimination laws. For instance, GINA’s employment related provisions include rules that will:

Prohibit employers and employment agencies from discriminating based on genetic information in hiring, termination or referral decisions or in other decisions regarding compensation, terms, conditions or privileges of employment;
Prohibit employers and employment agencies from limiting, segregating or classifying employees so as to deny employment opportunities to an employee based on genetic information;
Bar labor organizations from excluding, expelling or otherwise discriminating against individuals based on genetic information;
Prohibit employers, employment agencies and labor organizations from requesting, requiring or purchasing genetic information of an employee or an employee’s family member except as allowed by GINA to satisfy certification requirements of family and medical leave laws, to monitor the biological effects of toxic substances in the workplace or other conditions specifically allowed by GINA;
Prohibit employers, labor organizations and joint labor-management committees from discriminating in any decisions related to admission or employment in training or retraining programs, including apprenticeships based on genetic information;
Mandate that in the narrow situations where limited cases where genetic information is obtained by a covered entity, it maintain the information on separate forms in separate medical files, treat the information as a confidential medical record, and not disclosure the genetic information except in those situations specifically allowed by GINA;
Prohibit any person from retaliating against an individual for opposing an act or practice made unlawful by GINA; and
Regulate the collection, use, access and disclosure of genetic information by employer sponsored and certain other health plans.

These employment provisions of GINA are in addition to amendments to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Employee Retirement Income Security Act of 1974 (ERISA), the Public Health Service Act, the Internal Revenue Code of 1986, and Title XVIII (Medicare) of the Social Security Act that are effective for group health plan for plan years beginning after May 20, 2009. Added together, employment related disability discrimination are large and growing, meriting stepped up risk assessment and management.

Health Care & Other Organizations Also Targeted For Violations Of Public Accommodation & Other Federal Disability & Other Disability Discrimination Laws

In addition to the well-known and expanding employment discrimination risks, public and private health care and housing providers also increasingly face disability discrimination exposures under various federal laws such as the public accommodation and other disability discrimination prohibitions of the ADA, Section 504, the Civil Rights Act and various other laws that the Obama Administration views as high enforcement priorities.

Section 504 requires recipients of Medicare, Medicaid, HUD, Department of Education, welfare and most other federal assistance programs funds including health care, education, housing services providers, state and local governments to ensure that qualified individuals with disabilities have equal access to programs, services, or activities receiving federal financial assistance. The ADA extends the prohibition against disability discrimination to private providers and other businesses as well as state and local governments including but not limited to health care providers reimbursed by Medicare, Medicaid or various other federal programs The ADA requirements extend most federal disability discrimination prohibits to health care and other businesses even if they do not receive federal financial assistance to ensure that qualified individuals with disabilities have equal access to their programs, services or activities. In many instances, these federal discrimination laws both prohibit discrimination and require health care and other regulated businesses to put in place reasonable accommodations needed to ensure that their services are accessible and available to persons with disabilities. Meanwhile the Civil Rights Act and other laws prohibit discrimination based on national origin, race, sex, age, religion and various other grounds. These federal rules impact virtually all public and private health care providers as well as a broad range housing and related service providers.

As a result of its stepped up enforcement of the ADA, Section 504 and other civil rights and nondiscrimination rules, OCR is racking up an impressive list of settlements with health care providers, housing and other businesses for violating the ADA, Section 504 or other related civil rights rules enforced by OCR. While OCR continues to wage this enforcement battle in the programs it administers, the Departments of Justice, Housing & Urban Development, Education, Labor and other federal agencies also are waging war against what the Obama Administration perceives as illegal discrimination in other areas. Along side their own enforcement activities, OCR and other federal agencies are maintaining a vigorous public outreach to disabled and other individuals protected by federal disabilities and other civil rights laws intended to make them aware of and to encourage them to act to enforce these rights. To be prepared to defend against the resulting risk of claims and other enforcement actions created by these activities, health care, housing and other U.S. providers and businesses need to tighten compliance and risk management procedures and take other steps to prepare themselves to respond to potential charges and investigations.

Recent Settlements Highlight Risk

Enforcement of Discrimination & Other Civil Rights Laws Obama Administration Priority Putting Public & Private Providers At Risk

These and other enforcement actions by OCR and other agencies demonstrate the significant increased federal emphasis on the enforcement of federal discrimination laws against private and public health care and housing providers, state and local governments and other businesses under the Obama Administration. In keeping with this renewed emphasis, the DCF settlementis one of a growing list of federal disability, national origin and other discrimination charges and settlements OCR, has brought over the past year against physicians, public and private hospitals, insurers, federally financed housing providers and other parties providing services financed under programs administered by OCR. As the Department of Housing and Urban Development (HUD), the Equal Employment Opportunity Commission (EEOC) and other federal agencies also similarly have increased emphasis in federal discrimination law enforcement during this period, health care providers and other federal program service providers need to be prepared to defend their programs and practices to withstand federal discrimination charges or other investigations by federal agencies, private plaintiffs or both.

Obama Administration Also Aggressively Prosecutes Disability Discrimination In Other Business Operations

Guarding against disability discrimination in employment is not the only area that businesses need to prepare to defend against. The Obama Administration also has trumpeted its commitment to the aggressive enforcement of the public accommodation provisions of the ADA and other federal disability discrimination laws. In June, 2012, for instance, President Obama himself made a point of reaffirming his administration’s “commitment to fighting discrimination, and to addressing the needs and concerns of those living with disabilities.”

As part of its significant commitment to disability discrimination enforcement, the Civil Rights Division at the Justice Department has aggressively enforced the public accommodation provisions of the ADA and other federal disability discrimination laws against state agencies and private businesses that it perceives to have improperly discriminated against disabled individuals. For instance, the Justice Department entered into a landmark settlement agreement with the Commonwealth of Virginia, which will shift Virginia’s developmental disabilities system from one heavily reliant on large, state-run institutions to one focused on safe, individualized, and community-based services that promote integration, independence and full participation by people with disabilities in community life. The agreement expands and strengthens every aspect of the Commonwealth’s system of serving people with intellectual and developmental disabilities in integrated settings, and it does so through a number of services and supports. The Justice Department has a website dedicated to disabilities law enforcement, which includes links to settlements, briefs, findings letters, and other materials. The settlement agreements are a reminder that private businesses and state and local government agencies alike should exercise special care to prepare to defend their actions against potential disability or other Civil Rights discrimination challenges. All organizations, whether public or private need to make sure both that their organizations, their policies, and people in form and in action understand and comply with current disability and other nondiscrimination laws. When reviewing these responsibilities, many state and local governments and private businesses may need to update their understanding of current requirements. Statutory, regulatory or enforcement changes have expanded the scope and applicability of disability and various other federal nondiscrimination and other laws and risks of charges of discrimination.

To help mitigate the expanded employment liability risks created by the ADAAA amendments, businesses generally should act cautiously when dealing with applicants or employees with actual, perceived, or claimed physical or mental impairments to decrease exposures under the ADA. Management should exercise caution to carefully and proper the potential legal significance of physical or mental impairments or conditions that might be less significant in severity or scope, correctable through the use of eyeglasses, hearing aids, daily medications or other adaptive devices, or that otherwise have been assumed by management to fall outside the ADA’s scope. Employers should no longer assume, for instance, that a visually impaired employee won’t qualify as disabled because eyeglasses can substantially correct the employee’s visual impairment.

Invest in Prevention To Minimize Liability Risks

In light of the expanding readiness of the EEOC, Justice Department, OCR, HUD and other agencies to investigate and take action against health care providers for potential violations of the ADA, Section 504 and other federal discrimination and civil rights laws, health care organizations and their leaders should review and tighten their policies, practices, training, documentation, investigation, redress, discipline and other nondiscrimination policies and procedures. In carrying out these activities, organizations and their leaders should keep in mind the critical role of training and oversight of staff and contractors plays in promoting and maintaining required operational compliance with these requirements. Reported settlements reflect that the liability trigger often is discriminatory conduct by staff, contractors, or landlords in violation of both the law and the organization’s own policies.

For More Information Or Assistance

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here. About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

HHS/DOJ Partner With Private Health Plans To Further Ramp Up Health Care Fraud Heat!

July 30, 2012

Health care providers and payers should ensure that practices for billing private payers can withstand the scrutiny of federal and state health care fraud enforcers after the July 26, 2012 announcement of a ground-breaking new public-private antifraud initiative between federal and state health care fraud fighters and a private insurers under which private insurers will share an unprecedented amount of private health claims data, fraud detection practices, and other coöperation with federal and state official fraud prevention and prosecution efforts.

Government Health Care Fraud Fighters Partner With Private Insurers

The Federal health care fraud fighting departmental duo of the Departments of Health and Human Services (HHS) Justice (DOJ) last week expanded their network of fraud fighting resources by launching a “ground-breaking” partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. HHS and DOJ say the following organizations and government agencies are among the first to join this partnership:

America’s Health Insurance Plans
Amerigroup Corporation
Blue Cross and Blue Shield Association
Blue Cross and Blue Shield of Louisiana
Centers for Medicare & Medicaid Services
Coalition Against Insurance Fraud
Federal Bureau of Investigations
Health and Human Services Office of Inspector General
Humana Inc.
Independence Blue Cross
National Association of Insurance Commissioners
National Association of Medicaid Fraud Control Units
National Health Care Anti-Fraud Association
National Insurance Crime Bureau
New York Office of Medicaid Inspector General
Travelers
Tufts Health Plan
UnitedHealth Group
U.S. Department of Health and Human Services
U.S. Department of Justice
WellPoint, Inc.

HHS & DOJ Say Partnering With Private Insurers Will Give Ongoing Anti-Fraud Efforts Even More Punch

In announcing the new partnership on July 26, 2012, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder touted this new voluntary, collaborative public-private arrangement as the “next step” in the Obama administration’s efforts to combat health care fraud.

“This partnership is a critical step forward in strengthening our nation’s fight against health care fraud,” said Attorney General Holder. “This Administration has established a record of success in combating devastating fraud crimes, but there is more we can and must do to protect patients, consumers, essential health care programs, and precious taxpayer dollars. Bringing additional health care industry leaders and experts into this work will allow us to act more quickly and effectively in identifying and stopping fraud schemes, seeking justice for victims, and safeguarding our health care system.”

“This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars,” Secretary Sebelius said. “Thanks to this initiative today and the anti-fraud tools that were made available by the health care law, we are working to stamp out these crimes and abuse in our health care system.”

Partnership Allows Feds To Use Private Payer Claims Data, Knowledge & Other Fraud Detection Resources

According to HHS and DOJ, the new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. Its goal is to reveal and halt scams that cut across a number of public and private payers. HHS and DOJ say the partnership will private insurers to share their anti-fraud insights more easily with investigators, prosecutors, policymakers and other stakeholders and law enforcement officials more effectively to identify and prevent suspicious activities, better protect patients’ confidential information and use the full range of tools and authorities provided by the Patient Protection & Affordable Care Act (Affordable Care Act) and other statutes to combat and prosecute illegal actions.

One unprecedented element of this partnership will involve the sharing of information on specific schemes, utilized billing codes and geographical fraud hotspots between the public and private partners. The partners say the planned sharing of claims data and other information will help partners prevent, detect and respond to potential health care billing fraud by:

Helping partners to take action, to prevent losses to both government and private health plans before they occur;
Improving their ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities;
In the future to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect health care fraud schemes.

Presumably, this will involve the extension of the use of state-of-the-art technology and data mining practices like those the Centers for Medicare & Medicaid Services (CMS) already uses to review claims, to track suspected fraud trends and flag suspected fraudulent activity.

Partnership Expands Use & Reach of New Affordable Care Act & Other Health Care Fraud Detection & Enforcement Tools & Collaboration

The partnership builds upon and extends the reach and use of expanded legal tools created by the Affordable Care Act and other laws that Federal and state officials are using in their highly publicized war against health care fraud, waste and abuse in Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and, increasingly, private insurance plans. Using these and other new tools, convictions under the Health Care Fraud and Abuse Control Program increased by over 27% (583 to 743) between 2009 and 2011, and the number of defendants facing criminal charges filed by federal prosecutors in 2011 increased by 74% compared with 2008 (1,430 vs. 821).

The Affordable Care Act and other legislative changes and related programs have significantly strengthened the powers of HHS, DOJ and other federal and state agencies to investigate and prosecute health care fraud. Among other things, these amendments and programs included :

Qui tam and other whistleblower incentives and programs that encourage employees, patients, competitors and others to report suspicious behavior;
Require providers, plans to self-identify, self-report and self-correct false claims and certain other non-compliance;
Increase the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses;
Create penalties for obstructing a fraud investigation or audit;
Make it easier for the government to recapture any funds acquired through fraudulent practices;
Make it easier for the Department of Justice (DOJ) to investigate potential fraud or wrongdoing at facilities like nursing homes;
Under the risk-based provider enrollment rules, providers and suppliers wishing to take part in Medicare, Medicaid, and CHIP who federal officials view as posing a higher risk of fraud or abuse now must undergo licensure checks, site visits and other heightened scrutiny including ongoing monitoring as part of the new Automated Provider Screening (APS) system CMS implemented in December 2011. The APS uses existing information from public and private sources to automatically and continuously verify information submitted on a provider’s Medicare enrollment application including licensure status Secretary to impose a temporary moratorium on newly enrolling providers or suppliers of a particular type or in certain geographic areas if necessary to prevent or combat fraud, waste, and abuse.
Increased information sharing and coördination of investigations and enforcement among states, CMS, and its law enforcement partners at the Office of the Inspector General (OIG) and DOJ including the highly publicized activities of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint effort between HHS and DOJ to fight health care fraud.
The power of CMS, in consultation with OIG, to suspend Medicare payments and require States to suspend Medicaid and SCHIP payments to providers or suppliers during the investigation of a credible allegation of fraud;
The deployment and use of the sophisticated data collection and mining technologies of CMS’ new Fraud Prevention System, which since June 30, 2011 has used advanced predictive modeling technology to screen all Medicare fee-for-service claims before payment and target investigative resources on areas that this profile identifies as reflecting heightened risks of health care fraud vulnerability to allow regulators and prosecutors to more efficiently identify and respond to suspected fraudulent claims and emerging trends;
Focused fraud prevention, detection and enforcement activities on Home Health agencies, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers and certain other categories of providers and suppliers that federal officials view as historically presenting heightened concerns;
Expansion of the overpayment detection and recovery activities ofthe Recovery Audit Contractor (RAC) program to Medicaid, Medicare Advantage, and Medicare Part D programs; and
Various other tools.

Health Plan Partnership Latest Wrinkle In Fed’s Efforts To Use Private Whistleblower & Other Resources To Find Fraud

The partnership with the health plans is the latest wrinkle in a growing network of private relationships and outreach that HHS and DOJ use to discover health care fraud. By partnering with health plans, HHS and DOJ have recruited the health plans to help federal officials find and redress potential fraud in public and private health plans.

HHS and DOJ already know the value of getting private citizens to watch for and report suspected illegal behavior. Indeed, expended qui tam and other whistleblower activities already are paying off big for federal officials. For example, a former executive’s qui tam claim helped bring about the settlement announced in June, 2012 under which Christus Spohn Health System Corporation recently paid more than $5 million to settle Justice Departmentclaims that it profited from violations of the False Claims Act by inappropriately admitted patients to inpatient status for outpatient procedures. The investigation leading to the settlement began in March 2008 after Christus – Shoreline’s former director of case management filed a lawsuit under seal under the qui tam provisions of the False Claims Act alleging the six hospitals were submitting false claims to the Medicare program by billing for services that should have been performed on an outpatient basis as if they were more expensive inpatient services. The allegations stated that these hospitals were routinely billing outpatient surgical procedures as if they required an inpatient level of care even though the patients often were discharged from the hospital in less than 24 hours. The federal False Claims Act empowers private citizens with knowledge of fraud against the United States to present those allegations to the United States by bringing a lawsuit on behalf of the United States under seal. If the government’s investigation substantiates those allegations, then the private citizen is entitled to share in any recovery. In this case, that person will receive 20% of the $5,100,481.74 recovery.

With qui tam and other reports of suspected fraud an increasingly frequent and valuable tool in the federal and state wars on health care fraud, officials have added a wide range of programs encouraging and in some cases financially rewarding individuals and businesses that report circumstances leading to fraud convictions. The partnership with health plans reflects the latest wrinkle in these efforts.

Health Care Providers & Health Plans Must Act To Manage Risks

In response to the growing emphasis and effectiveness of Federal officials in investigating and taking action against health care providers and organizations, health care providers covered by federal false claims, referral, kickback and other health care fraud laws should consider auditing the adequacy of existing practices, tightening training, oversight and controls on billing and other regulated conduct, reaffirming their commitment to compliance to workforce members and constituents and taking other appropriate steps to help prevent, detect and timely redress health care fraud exposures within their organization and to position their organization to respond and defend against potential investigations or charges. In light of the growing qui tam risks, health care providers also should tighten internal investigation, exit interview and other human resources and business partner oversight, reporting and investigation policies and practices to help find and redress potential fraud or other qui tam, retaliation and similar exposures early and more effectively.

For More Information Or Assistance

If you need help reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to establish and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need help responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here.

About Solutions Law Press

Leave a Comment » | Academic medicine, Anti-KickBack, ASC, DME, Doctor, Durable Medical Equipment, Electronic Health Records, Electronic Medical Records, Employee Benefits, false claims act, Federal Sentencing Guidelines, Grants, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health IT, Medicaid, Medical Malpractice, Medicare, Medicare Advantage, Mental Heatlh, Money Laundering, OIG, Outpatient, Physician, Prescription Drugs, Rural Health Care, Stark, Uncategorized | Tagged: CMS, DOJ, false claims act, Health Care, health care feraud, Health claims, Health Plans, HHS, Hospitals, Justice Department, OIG, qui tam, Whistleblower | Permalink
Posted by Cynthia Marcotte Stamer

ONC Releases Proposed Rules For Meaningful Use Stage 2

February 23, 2012

The Office of the National Coordinator for Health Information Technology (ONC) published its Notice of Proposed Rulemaking for Stage 2 Meaningful Use (Proposed Rule) in the Federal Register today (February 23).

The Proposed Rule available here outlines the next stage of meaningful use for the Electronic Health Record (EHR) Incentive Programs administered by CMS.

CMS has developed a fact sheet to give providers an overview of the rule and how Stage 2 expands upon Stage 1 of meaningful use. The fact sheet can be found here.

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related technology, risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers, health care technology and other health industry clients to set up and administer privacy and technology; workforce and staffing; operations; compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Update Charity and Sliding Fee Scale Policies For 2012 Federal Poverty Rate Changes

February 21, 2012

Health care and other social service agencies should review and update their charity care or sliding fee scale policies in response to the 2012 Poverty Guidelines published in late January by the U.S. Department of Health and Human Services published updated federal poverty guidelines for 2012. See here. Today, the U.S. Department of Labor followed up by releasing its updated 2012 Poverty Guidelines

Many federal programs use the federal poverty guidelines as one criterion for federal program eligibility. For example, the Medicaid and State Children’s Health Insurance (SCHIP) programs determine eligibility largely on the basis of whether the applicant’s income is below the federal poverty guidelines. Other programs determine financial eligibility based on a percentage or multiplier of the federal poverty guidelines (for example, 125 percent of federal poverty guidelines). In addition, the federal poverty guidelines are used in the immigration context, such as the required Affidavit of Support.

For 2012, the federal poverty guideline in the 48 contiguous states and Washington, D.C., for a family of 4 is 23,050. For each additional person, the poverty guideline goes up by $3,960. Alaska and Hawaii have slightly higher poverty guidelines.

Many health care and social services organizations, especially non-profit organizations, use a sliding fee scale or fee waiver based on the federal poverty guidelines. In addition, many health care organizations base their charitable care policies on the federal poverty guidelines. While use of the federal poverty guidelines is not mandated by law except by federally funded programs, keep in mind that the Joint Commission as part of its accreditation and survey process may ask whether the organization has used the most recent update to the federal poverty guidelines in its sliding scale or fee waiver policies. Therefore, if your organization will be surveyed in the near future, you should review the charity care or fee waiver policies as part of your preparation for the survey.

For More Information Or Assistance

If you need help reviewing or responding to health care related policy, risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to set up and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need help responding to concerns about the matters discussed in this publication or other health care concerns, wish to get information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here.

About Solutions Law Press

Leave a Comment » | Childrens Health Insurance Program, Doctor, Grants, Health Care, Health Care Provider, Hospital, Indian Health, Medicaid, Medicare, Medicare Advantage, Physician, Prescription Drugs | Tagged: controlled substance, DEA, Drug Testing, drugs, false claims act, Health Care, Health Care Compliance, Health Care Fraud, HEAT, licensure, Medicaid, Medical Board, Medicare, pain management, pharmacist, pharmacy, physical therapy, Physician, poverty rates | Permalink
Posted by Cynthia Marcotte Stamer

North Texas Medical Supply Company Owner Indicted For Health Care Fraud Now Also Charged With Immigration Fraud

December 27, 2011

A Plano, Texas man already indicted for health care fraud now also faces federal immigration fraud related changes. Justice Department officials announced the additional charges against Okey F. Nwagbara, (Nwagbara) on December 20, 2011. Although Nwagbara’s alleged actions reflect potential criminal misconduct in many areas, health care providers should keep in mind that the health care fraud task force participants are targeting health care fraud of all types, including those my health care providers not engaged in other types of criminal misconduct. As a result, all health care providers should tighten their health care billing and other practices to defend against possible scrutiny as part of the federal or state government’s widening fraud audit and investigation efforts.

Nwagbara Indicted For Health Care Fraud In October, 2011

Nwagbara 45 already is awaiting trial later in Spring, 2012 on health care fraud charges announced in October, 2011. According to the Justice Department, a North Texas grand jury indicted Nwagbara along with Jerry C. Bullard, 55, Mesquite, Texas, in October, 2011 on felony charges related to a health care fraud scheme they allegedly ran that defrauded Medicare of more than $500,000.

According to the Justice Department, Nwagbara is the owner/operator of Advanced MedEquip and Supplies Limited, located at 331 Melrose Drive in Richardson, Texas. Bullard is a former employee of Medistat Group Associates, P.A., an association of health care providers located in Desoto, Texas.

The October health care fraud indictment charges Nwagbara and Bullard each with one count of conspiracy to commit health care fraud and six substantive counts of health care fraud. The indictment alleges that from June 2008 through March 2010, Nwagbara and Bullard conspired together to defraud Medicare by submitting more than $500,000 in claims to the Medicare program for enternal nutrition DME, when in fact such DME was not medically necessary and in many cases, not provided.

According to the health care fraud indictment, Bullard worked in the Durable Medical Equipment (DME) section of Medistat where he was in charge of handling physicians’ prescriptions for equipment. Bullard and Nwagbara had a kickback arrangement and Bullard placed orders for DME with Nwagbara’s company, Advanced.

The indictment claims Bullard, using a Medistat physician’s name, would sign prescriptions, DME information forms and certificates of medical necessity for Medicare beneficiaries falsely indicating, among other things, that a beneficiary had a feeding tube when in fact, the beneficiary did not.

The enteral nutrition products which were billed to Medicare are consumed by a patient through a feeding tube. The associated feeding supply kits include tubing and syringes. The indictment claims that both the enteral formula and the kits that Advanced billed to Medicare were not medically necessary because the beneficiaries were not receiving nutrition through a feeding tube, the indictment claims. Instead, beneficiaries were receiving flavored nutritional supplements such as Ensure® and Glucerna® that would be consumed orally. Medicare does not reimburse orally ingested nutritional supplements.

In addition, the health care fraud indictment alleges that Nwagbara supplied only a fraction of the enternal products for which he billed Medicare and many of the beneficiaries never received the feeding supply kits for which he also billed Medicare.

The health care fraud case is being investigated by the Dallas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Strike Force, which includes the U.S. Department of Health and Human Services – Office of Inspector General, the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Prior to the announcement of the other charges, his trial on the health care fraud charges was scheduled for March, 2012. It is not clear whether the new charges will delay these proceedings.

New Immigration Charges

On December 20, 2011, the Justice Department announced that a North Texas grand jury now also has indicted Nwagbara for making misrepresentations in immigration and naturalization documents that misled the government and prevented the government from examining material facts that may have prevented his naturalization according to a December 20, 2011 Justice Department announcement.

According to the December 20, 2011 announcement by U.S. Attorney Sarah R. Saldaña, the immigration charges resulted from investigative work by the Dallas Health Care Fraud Strike Force, in concert with U.S. Immigration and Customs Enforcement’s Homeland Security Investigations and U.S. Citizenship and Immigration Services.

The new immigration indictment alleges that Nwagbara entered into a fraudulent marriage and provided false statements to obtain citizenship. On January 30, 2008, he made false statements on his application for naturalization that included:

Verifying that he had been married to and living with the same U.S. citizen for the last three years, when he was not living with his U.S. citizen spouse;
Indicating that he had no children, when in fact he had two children; and
Indicating that he had never previously claimed to be a U.S. citizen, when in fact, he falsely stated on a mortgage application in January 2006 that he was a U.S. citizen.

According to Saldaña, the immigration related indictment charges Nwagbara with three counts of making a false statement in an immigration document and three counts of unlawful procurement of naturalization. If convicted, each count carries a maximum statutory sentence of 10 years in federal prison and a $250,000 fine. Furthermore, should Nwagbara be convicted of unlawfully procuring his naturalization, his status as a U.S. citizen will be revoked by court order.

The Justice Department announcements reminds readers that an indictment is an accusation by a federal grand jury, and a defendant is entitled to the presumption of innocence unless proven guilty.

Health Care Fraud Charges Part of Ongoing National Anti-Health Care Fraud Campaign

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. The joint Department of Justice-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Since its announcement, the Strike Force has used the combined resources of agents from the FBI, HHS-Office of Inspector General (HHS-OIG), multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies to investigate and prosecute a rising number of organizations and individuals throughout the industry for alleged violations of Federal health care fraud prohibitions. In their September 7, 2011 announcement, HHS and DOJ credited Strike Force Operations in nine locations with resulting in charges against more than 1,140 defendants who the government charged collectively falsely billed the Medicare program for more than $2.9 billion.

In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are using a wide range of new and old tools in their campaign against what they perceive as fraudulent providers and to deter other perceived aggressiveness by health care providers and organizations. See e.g., U.S. to use software to crack down on Medicare, Medicaid, CHIP fraud; Health Care Fraud Enforcement Packs New Heat; OIG Shares Key Insights On When Owners, Officers & Managers Face OIG Program Exclusion Based On Health Care Entity Misconduct; OIG Launch of Health Care Fraud “Most Wanted” List Sign of Enforcement Risks; CMS Delegated Lead Responsibility For Development of New Affordable Care Act-Required Medicare Self-Referral Disclosure Protocol; HHS announces Rules Implementing Tools Added By Affordable Care Act to Prevent Federal Health Program Fraud.

The effectiveness of these Federal efforts to deter, find and prosecute false claims and other perceived abuses of Federal health care law has been significantly strengthened since Congress passed the Patient Protection & Affordable Care Act (Affordable Care Act). Among other things, ACA empowered HHS to:

Suspend payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
Impose a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
Terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
Require provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

Act To Manage Risks

For More Information Or Assistance

Board Certified in Labor & Employment Law, Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients.

Throughout her career, Ms. Stamer has advised and represented health care providers and other health industry clients. She helps health industry clients to establish and administer compliance and risk management policies and to respond to health care, human resources, tax, privacy, safety, antitrust, civil rights, and other laws as well as to handle public policy and government relations, peer review and credentialing, performance and discipline, training, internal investigation, litigation and enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on health care fraud, privacy, and other rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

You can learn more information about Ms. Stamer’s health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Resources

If you found this update of interest, you also may be interested in reviewing some of the other updates and publications authored by Ms. Stamer available including:

About Solutions Law Press

Leave a Comment » | Academic medicine, Anti-KickBack, ASC, Childrens Health Insurance Program, Corporate Compliance, DME, Doctor, Durable Medical Equipment, false claims act, Federal Health Center, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Home Health, Hospital, Hospital, Medicaid, Medicare Advantage, Mental Heatlh, Money Laundering, OIG, Pharmacy, Physician, Reimbursement, Stark | Tagged: DOJ, Health Care, Health Care Fraud, Hospital, Medicare Fraud, OIG, Physician | Permalink
Posted by Cynthia Marcotte Stamer

DOL Proposes Tighter Overtime, Minimum Wage Rules For Home Care Workers, Continues Scrutiny Of Health Care Employers

December 15, 2011

The U.S. Department of Labor Wage and Hour Division (WHD) plans to propose new rules that would provide minimum wage and overtime protections for nearly two million workers who provide in-home care services for the elderly and infirm. WHD’s focus on home health workers is an extension of its expanded regulation and enforcement efforts targeting a broad range of health care industry employers. Home care and other health industry employers should act to manage their rising exposures to minimum wage, overtime and other federal and state wage and hour law risks. Additionally, health industry and other employers concerned about the potential cost or other implications of the proposed regulatory changes also should consider submitting comments to the WHD by the February comment deadline.

On December 15, 2011 the WHD announced that it will publish a Notice of Proposed Rulemaking [1] (NPRM) to revise the companionship and live-in worker regulations under the Fair Labor Standards Act (FLSA):

To more clearly define the tasks that may be performed by an exempt companion;
To limit the companionship exemption to companions employed only by the family or household using the services; and
To provide that third party employers, such as in-home care staffing agencies, could not claim the companionship exemption or the overtime exemption for live-in domestic workers, even if the employee is jointly employed by the third party and the family or household.

When Congress expanded protections to “domestic service” workers in 1974, it exempted casual babysitters and companions for the aged and inform from both the minimum wage and overtime pay requirements of the FLSA and exempted live-in domestic workers from the overtime pay requirement only. While WHD has left regulations governing this exemption substantially unchanged since first issued in 1975, it now believes the in-home care service industry. workers employed by in-home care staffing agencies are not the workers that Congress envisioned in enacting the companionship exemption (i.e., neighbors performing elder sitting).

As a result of these determines, WHD is moving to modify its existing rules to broaden protections for professionally employed home care workers as well as outreaching to inform employers and workers about the requirements that it perceives employers of these workers must meet.

The proposed tightening of regulations for home health workers follows a general toughening by WHD of its regulation and enforcement of wage and hour laws in the health care industry. See, e.g. Home health care company in Dallas agrees to pay 80 nurses more than $92,000 in back wages following US Labor Department investigation; US Department of Labor secures nearly $62,000 in back overtime wages for 21 health care employees in Pine Bluff, Ark.; US Department of Labor initiative targeted toward increasing FLSA compliance in New York’s health care industry; US Department of Labor initiative targeted toward residential health care industry in Connecticut and Rhode Island to increase FLSA compliance; Partners HealthCare Systems agrees to pay 700 employees more than $2.7 million in overtime back wages to resolve U.S. Labor Department lawsuit; US Labor Department sues Kentucky home health care provider to obtain more than $512,000 in back wages and damages for 22 employees; and Buffalo, Minn.-based home health care provider agrees to pay more than $150,000 in back wages following US Labor Department investigation.

Coupled with these and other enforcement efforts against health industry employers, WHD’s announcement of plans to tighten rules for home care givers. In connection with its announcement of the planned regulatory changes, for instance, WHD highlighted the following guidance about the wage and hour rules that employers of home care workers can anticipate being required to meet when employing these workers:

Violation of wage and hour laws exposes health care and other employers to significant back pay awards, substantial civil penalties and, if the violation is found to be willful, even potential criminal liability. Because states all have their own wage and hour laws, employers may face liability under either or both laws.

In light of the proposed regulatory changes and demonstrated willingness of WHD and private plaintiffs to bring actions against employers violating these rules, health care and others employing home care workers should take well-documented steps to manage their risks. These employers should both confirm the adequacy of their practices under existing rules, as well as evaluate and begin preparing to respond to the proposed modifications to these rules. In both cases, employers of home care or other health care workers are encouraged to critically evaluate their classification or workers, both with respect to their status as employees versus contractor or leased employees, as well as their characterization as exempt versus non-exempt for wage and hour law purposes. In addition, given the nature of the scheduled frequently worked by home care givers, their employers also generally should pay particular attention to the adequacy of practices for recordkeeping.

For More Information Or Assistance

Throughout her career, Ms. Stamer has advised and represented health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to health care, human resources, tax, privacy, safety, antitrust, civil rights, and other laws as well as with internal investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on OCR Civil Rights rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Resources

If you found this update of interest, you also may be interested in reviewing some of the other updates and publications authored by Ms. Stamer available including:

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[1] WHD’s announcement of the planned rule notes that this draft shared December 15 remains subject to change before formally published in the Federal Register

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Posted by Cynthia Marcotte Stamer

Former Houston Texas Physician Gets 70 Month Prison Sentence For Fraud Conviction

November 27, 2011

A Federal court on November 14, 2011 sentenced Armando Chavez, 42, a former physician and owner of the Chavez Medical Group in East Houston to 60 months for the conspiracy charge and to 70 months for each of the three mail fraud charges. In addition to the prison sentences, which will run concurrently, Chavez was also ordered to pay $3,821,082 in restitution.

The prosecution and sentencing of Chavez highlights the heightened risk that physicians and others engaging in aggressive health care billings risk if Federal officials view their actions as crossing the line. The Chavez case is particularly notable as it primarily stemmed from claims submitted to private health care payers.

The Chavez sentence resulted from Chavez’ guilty plea to one count of conspiracy and three counts of mail fraud in connection with billings made at the Chavez Medical Group.

The charges brought in April, 2011 stem from improper billing at the Chavez Medical Group between 2005 and 2007. Federal prosecutors charged that Chavez billed for services he did not perform through a process of “unbundling” medical codes used on claims he filed to increase the amount he was paid by insurance companies. While most health care providers recognize potential exposures to health care fraud prosecution for making false claims to Medicare, Medicaid or other federal programs, many providers fail to recognize this same exposure also can result from false billings to private health plans and insurers.

Following the initiation of the investigation, Chavez voluntarily surrendered his medical license to the Texas Board of Medicine. Filing false health care claims is one of many types of personal misconduct that justifies loss of licensure or other discipline under Texas Medical Board rules.

According to the documents filed of record in the case, Chavez was board certified in internal medicine, licensed by the Texas Board of Medicine in 1997. He started his medical practice in family medicine and in 2005, began to perform endovenous laser ablation, a procedure used to repair varicose veins in the legs.

For purposes of billing, the medical insurance industry provides certain billing codes for the laser ablation procedure, which include a group of procedures billed under one code for the entire procedure. Chavez instructed his staff to “unbundle” or separate the codes for this procedure and to bill for individual steps in the procedure, resulting in greater reimbursement and payment for each patient. Additionally, Chavez submitted claims alleging he repaired all six veins for each patient, when in fact – in most cases – he repaired fewer than six veins. By alleging he repaired all six veins, Chavez alleged he performed six procedures over a period of six days, another aspect of the fraudulent billing which he used to justify the unbundling of codes and allowed him to be reimbursed at the highest possible rate.

Federal prosecutors claimed The typical patient whose billing was submitted as “bundled” into one code resulted in payment of approximately $6000, while the patient whose billing codes were “unbundled” typically resulted in payment of approximately $14,000. Based on these figures, Federal prosecutors claim that Chavez billed insurance companies and programs, including Medicare and Medicaid, a total of $14.1 million for which he collected $3.8 million between 2005 and 2007.

The investigation of this case was conducted by the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Assistant United States Attorney Cedric L. Joubert prosecuted the case. According to the Justice Department, the case is being investigated by the Dallas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Strike Force, which includes the U.S. Department of Health and Human Services Office of Inspector General, the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,140 defendants who collectively have falsely billed the Medicare program for more than $2.9 billion.

While health care fraud enforcement remains a lead Federal priority, health care providers in Texas and other HEAT Strike Force targeted regions face heightened exposures to HEAT task force scrutiny and prosecution. In response to these and other investigation and oversight activities, health care providers should strengthen their compliance practices and oversight and take other special care to position themselves and their billings to defend against possible challenge.

For Help With Compliance, Investigations Or Other Needs

If you need assistance providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Euless Healthcare Corporation Owner, Associates Face Conspiracy And Health Care Fraud Charges For Alleged Submission Of $700,000+ In Fraudulent Health Care Claims

November 27, 2011

Three defendants indicted for engaging in various Federal health care fraud offenses related to their involvement in the operation of a North Texas based health care company, Euless Healthcare Corporation, were arrested on November 17, 2011. The charges highlight the health care fraud risks that health care providers, their owners and leaders face for engaging in activities that Federal officials view as prohibited under health care fraud laws.

According to the Justice Department, a 10-count indictment unsealed against Ovsanna Agopian, aka “Joanna Ovsanna,” “Joanna Smbatyan,” and “Ovsanna Agopian,” Boghos Babadjanian and Tolulope Labeodan charges each defendant wit one count of conspiracy to commit health care fraud and nine substantive counts of health care fraud.

According to the indictment, Agopian was the principal operator of Euless Healthcare Corporation (EHC), located at 222 West Bedford Euless Road in Hurst. Babadjanian was the owner of EHC and Labeodan was an employee of EHC. The indictment alleges that the three defendants ran a conspiracy to defraud Medicare by submitting claims for office visits and diagnostic tests that were never performed. The indictment alleges that Agopian recruited doctors to work for EHC by telling them that they would treat beneficiaries in the beneficiaries’ homes. However, the doctors that Agopian recruited never saw beneficiaries at the EHC clinic or beneficiaries’ homes. Prosecutors claim Agopian directed Labeodan, who is not a medical professional and does not have a Medicare provider number, to take beneficiary files from the EHC clinic and purportedly see beneficiaries. However, many beneficiaries, in whose names EHC submitted claims for reimbursement, have never heard of EHC or any of the doctors Agopian recruited.

Federal prosecutors claim that EHC used those doctors’ Medicare provider numbers to falsely bill Medicare more than $700,000 for office visits and diagnostic test for which the defendants allegedly collected Medicare reimbursement checks totaling more than $370,000.

According to the Justice Department, the case is being investigated by the Dallas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Strike Force, which includes the U.S. Department of Health and Human Services Office of Inspector General, the FBI and the Texas Attorney General’s Medicaid Fraud Control Unit. Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,140 defendants who collectively have falsely billed the Medicare program for more than $2.9 billion.

For Help With Compliance, Investigations Or Other Needs

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Posted by Cynthia Marcotte Stamer

Medical Identity Theft/Fraud Convictions Highlight Need For Health Care Providers To Safeguard Health Information, Guard Against Fraud Schemes

November 27, 2011

Convictions Highlight Health Care Data Bases Attractive, Vulnerable Target For Medicare Fraud Schemers

A Federal judge sentenced 25 year old Miami resident Yenky Sanchez, 25 to serve more than 5 years in Federal prison for his role in the theft of Medicare numbers and other information of elderly and disabled Florida residents as part of a plan to defraud Medicare, Medicaid and other federal programs. Coming on the heels of a November 3 conviction in West Virginia of Sargis Tadevosyan in a separate identity theft for Medicare fraud scheme, the convictions highlight the growing commitment and effectiveness of Federal and state investigators in investigating and prosecuting individuals who seek to use identity theft schemes to defraud Medicare or other federal programs.

Sanchez Conviction & Sentencing

The sentence arises from criminal charges brought by the U.S. Department of Justice (DOJ) in conjunction with other federal and state agencies, which charged Sanchez considered to commit health care fraud, authentication feature fraud and aggravated identity theft. According to DOJ documents, Sanchez, participated in a scheme with Raul Diaz-Perera, to steal and sell Medicare numbers and other data about clients of their employer, the Florida Department of Children and Families’ (DCF). Diaz-Perera previously was employed with DCF. According to the evidence at trial against Sanchez and a factual proffer filed with the court during the plea hearing for co-defendant Diaz-Perera, Sanchez used his position as employees at a DCF call center in downtown Miami to steal Medicare numbers and other personal information for purposes of committing health care fraud and identity theft. The intent of Sanchez and his co-conspirator was for those numbers to be used to fraudulently bill Medicare for services that were never provided to the DCF beneficiaries. Sanchez was convicted of conspiring to commit health care fraud, in violation of Title 18, United States Code, Section 1349; conspiring to commit authentication feature fraud, in violation of Title 18, United States Code, Sections 1028(a)(3) and (f); and aggravated identity theft, in violation of Title 18, United States Code, Section 1028A(a)(1). Based on these convictions, U.S. District Judge Cecilia M. Altonaga sentenced Sanchez on November 21, 2011 to 65 months in prison, followed by three years of supervised release. Judge Altonaga also imposed a $5,000.00 fine on Sanchez.

Tadevosyan Conviction

Federal officials previously also had scored another Medicare fraud/identity theft prosecution victory just a few short weeks earlier in West Virginia. On November 3, 2011, a federal jury convicted Armenia citizen Sargis Tadevosyan in connection with a health care fraud scheme that intended to defraud millions of dollars from Medicare. Tadevosyan was found guilty of two felony counts: conspiracy to commit health care fraud and wire fraud and aggravated identity theft. Tadevosyan faces up to 20 years in prison for the conspiracy conviction and a mandatory consecutive sentence of two years for aggravated identity theft and a $250,000 fine when he is sentenced on January 26, 2012.

In contrast to the small scale conspiracy that apparently occurred in the Sanchez case, the Tadovosyn scheme apparently was orchestrated by organized crime. Department of Health and Human Resources Office of Inspector General (HHS-OIG) uncovered the activities of Tadovosyn as part of its investigation of fraud schemes involving false front providers, whereby a company posed as a Medicare health care provider, and unlawfully billed Medicare as if they were providing legitimate services. Ultimately, investigators discovered that Tadevosyn and others were involved in defrauding Medicare and other health care payers as part of a scheme that used false front provider companies. In total, more than $4 million in Medicare claims were submitted by the false front providers. To co-conspirators of Tadevosyn pleaded guilty in September to aiding and abetting aggravated identity theft in connection to the health care fraud plot. Those two co-defendants are scheduled to be sentenced on December 1, 2011.

In announcing the Tadevosyan conviction, federal officials affirmed their commitment to finding and prosecuting identity theft targeting Medicare and other health insurance programs. “This investigation revealed that organized criminal groups are still brazenly attempting to steal taxpayer money from our national health insurance programs,” said Nicholas DiGiulio, Special Agent in Charge for the Inspector General’s Office of the United States Department of Health and Human Services. “Today’s results demonstrate that we will do whatever it takes to catch these individuals in the act before they receive a penny of taxpayers’ money.”

Federal Laws, Investigations & Prosecutions of Medical Identity Theft Schemes Tightening

Whether from deliberate schemes to misappropriate data or other less sinister compromises of personal health information or other sensitive data, health care providers, health plans and other businesses face rising responsibilities to protect data and increasing exposures for failing to do so.

Federal law imposes stiff sanctions against organizations and individuals that engage in theft of personal or other sensitive information, health or other federal program fraud or both. In an effort to stem the tide of health care and identity theft fraud, federal and state legislators and regulators have tightened federal and state laws to strengthen laws prohibiting health care fraud and identity theft, to require that health care providers, health plans, federal and state agencies and others that collect, possess or access sensitive personal health information, personal financial information or other sensitive date safeguard and protect sensitive information against improper access or misuse, to increase the penalties for violation of these federal and state laws and to provide law enforcement with expanded tools to investigate and prosecute violations of these laws. See e.g., Cybercrime and Identity Theft: Health Information Security Beyond HIPAA.

As a result of these new and expanded mandates, health care providers, health plans, financial organizations and a broad range of other businesses and governmental agencies face a host of complicated mandates to protect personal health information, personal financial information and other sensitive data under laws such as the Health Information Portability & Accountability Act (HIPAA), the Fair & Accurate Credit Transactions Act (FACTA), state and federal identity theft and data security and other laws and significant liability for failing to fulfill these responsibilities.

Health care providers, health insurers and others handling protected health information are particularly at risk when their data is compromised. Recent amendments to HIPAA require these entities and their business associates to tighten their data privacy and security safeguards and to monitor and timely report data breaches, as well as significantly expand their potential liability exposure for failing to comply with HIPAA’s requirements. See e.g., UCLA Health Systems Payment of $865,500 To Settle HIPAA Charges Shows Rising HIPAA Risk; CVS Settles Privacy Charges; Rite Aid Agrees to Pay $1 Million to Settle HIPAA Privacy Case As Office of Civil Rights Proposes Tighter HIPAA Privacy & Security Regulations; 2 New HIPAA Criminal Actions Highlight Risks From Wrongful Use/Access of Health Information; President Signs Long-Sought Red Flag Rule Exemption Into Law. As part of its ongoing implementation of stepped up enforcement responsibility and powers enacted as part of these recent amendments, the HHS Office of Civil Rights (OCR) announced on November 8, 2011 its kickoff of a new compliance audit effort. These developments send a forceful message that all businesses generally and health care providers, health plans, healthcare clearinghouses and their business associates specifically must get serious about compliance with the privacy, security and data breach requirements of HIPAA and other applicable law by implementing and administering the policies, procedures, training and oversight necessary to comply with these and other federal and state mandates regarding the protection of personal health information and other sensitive data. Learn more about the recent convictions and related data breach exposures here.

For Help With Compliance, Investigations Or Other Needs

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Posted by Cynthia Marcotte Stamer

Detroit-Area Foot Doctor Pleads Guilty to Medicare Fraud Scheme

November 27, 2011

A Detroit-area foot doctor pleaded guilty to health care fraud on November 22 for his participation in a Medicare fraud scheme. The guilty plea highlights the expanding reach of the heightened health care fraud detection and enforcment emphasis of Federal officials and the resulting need for heightened care by physicians and other health care providers in their health care billing and other operations to guard against getting caught in this expanding net.

According to the Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and the Department of Health and Human Services (HHS), podiatrist Errol Sherman pleaded guilty in the Eastern District of Michigan to one count of health care fraud. At sentencing, Sherman faces a maximum penalty of 10 years in prison and a $250,000 fine

According to the plea documents, between January 2003 and December 2006, Sherman billed Medicare and Blue Cross Blue Shield of Michigan for a procedure known as an “avulsion of the nail plate” or “nail avulsion” procedure thousands of times with respect to hundreds of beneficiaries. According to court documents, Sherman billed Medicare for nail avulsion procedures never rendered.

Since their start in March 2007, the Medicare Fraud Strike Force operations in nine districts have charged thousands of individuals with falsely billing Medicare or more than $2.9 billion.

The rising emphasis of DOJ, HHS and other federal and state officials on health care fraud detection and enforcement requires that health care providers tighten their billing, medical record keeping, training and other compliance efforts to guard against false claims and other health care fraud charges.

For Help With Compliance, Investigations Or Other Needs

If you need help providing compliance or other training, reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to set up and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

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Posted by Cynthia Marcotte Stamer

Joint Commission Equal Visitation Rules & Guidance Supplement New Medicare Equal Visitation Requirements

November 13, 2011

Following on recently finalized Medicare regulations dictating that hospitals allow patients to control individuals who will be allowed to visit or exercise other patient representative rights , the Joint Commission of the Accreditation recently has released the following new guidance concerning its expectations concerning the responsibilities of hospitals and other accredited entities to create inclusive care enviromentments for lesbian, gay, bisexual and transgender (LGBT) patients and their families:

Joint Commission focuses on improving care for LGBT patients – A new field guide posted November 8, 2011- from The Joint Commission urges U.S. hospitals to create a more welcoming, safe and inclusive environment that contributes to improved health care quality for LGBT patients and their families.
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community – A new field guide from the Joint Commission urges US hospitals to create a more welcoming, safe, and inclusive environment that contributes to improved health care quality for lesbian, gay, bisexual, and transgender (LGBT) patients and their families.

Hospitals and others impacted by these rules should review and update visitation, patient representative, privacy, patient notification and consent and other policies and practices to comply with the new Medicare mandates and the applicable requirements of the new Joint Commission standards.

Learn more about these new requirements in the recent Modern Healthcare article Bumpy road for equal visitation.

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Ms. Stamer’s insights on the new Medicare visitation rules recently were quoted in Modern Healthcare. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on OCR Civil Rights rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Posted by Cynthia Marcotte Stamer

OCR Audit Program Kickoff Further Heats HIPAA Privacy Risks

November 9, 2011

The kickoff of a new compliance audit pilot program provides another reason for health care providers, health plans, healthcare clearinghouses and their business associates to get serious about compliance with the privacy, security and data breach requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

OCR Pilot Audit Program Begins

On November 8, 2011, the Office of Civil Rights (OCR) of the Department of Health & Human Services (HHS) announced that it will begin auditing HIPAA compliance this month under a new pilot program.

As amended by the American Recovery and Reinvestment Act of 2009 in Section 13411 of the HITECH Act, requires HHS to provide for periodic audits to make sure covered entities and business associates are complying with the HIPAA Privacy and Security Rules and Breach Notification standards. To carry out this mandate, OCR is piloting a program to perform up to 150 audits of covered entities to assess privacy and security compliance between November 2011 and December 2012.

The commencement of OCR HIPAA compliance audits is yet another sign that covered entities and their business associates should get serious about HIPAA compliance. The audit program serves as a new part of OCR’s health information privacy and security compliance program. While OCR says that it presently views the pilot audits as primarily a compliance improvement tool, this does not mean violators should expect a free walk.

Even before the impending audits, HIPAA Privacy exposures of covered entities for failing to comply with HIPAA already had risen significantly. Earlier this year, OCR imposed a $4.3 Million Civil Money Penalty (CMP) against Cignet Health of Prince George’s County (Cignet) for violating HIPAA. Meanwhile, the Department of Justice has secured several criminal convictions or pleas under HIPAA’s criminal provisions. Under amendments made by the HITECH Act, state attorneys general also now are empowered to bring civil lawsuits against covered entities and business associates that commit HIPAA violations that injure citizens in their state under certain circumstances. Eventually, individuals injured by HIPAA violations also will get the right to share in a portion of certain HIPAA recoveries.

These and other audit and enforcement activities send a strong message that covered entities and their business associates need to get serious about HIPAA compliance. As stated by OCR Director Georgina Verdugo when announcing the Mass General Resolution Agreement, “To avoid enforcement penalties, covered entities must ensure they are always in compliance with the HIPAA Privacy and Security Rules,” Verdugo added, “A robust compliance program includes employee training, vigilant implementation of policies and procedures, regular internal audits, and a prompt action plan to respond to incidents.” Learn more here.

For Help With Monitoring Developments, Compliance, Investigations Or Other Needs

Vice President of the North Texas Health Care Compliance Professionals Association, a member of the American College of Employee Benefit Counsel, Past Chair of the ABA RPTE Employee Benefits & Other Compensation Arrangements Group, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has extensive experience advising and assisting health care providers, health plans, their business associates and other health industry clients to establish and administer medical privacy and other compliance and risk management policies. Ms. Stamer also regularly helps clients deal with OCR and other agencies, publishes and speaks extensively on medical and other privacy and data security, health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. Her insights on the required “culture of compliance” with HIPAA are frequently included in medical privacy related publications of the Atlantic Information Service, Modern Health Care, HealthLeaders and many others. Among others, she has conducted privacy training for the Association of State & Territorial Health Plans (ASTHO), the Los Angeles Health Department, the American Bar Association, the Health Care Compliance Association, a multitude of health industry, health plan, employee benefit and other clients, trade and professional associations and others. You can get more information about her HIPAA and other experience here or may contact her at (469) 767-8872 or via e-mail here.

You can review other selected publications and resources and additional information about the employment, employee benefits and other experience of Ms. Stamer here.

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Posted by Cynthia Marcotte Stamer

OCR Settlements Show Health Care & Disabled Housing Providers Face Growing Disability Discrimination Risks

October 19, 2011

A continuing series of federal investigations and enforcement actions highlight the need for health care providers and other health industry organizations to strengthen their disability discrimination management practices to defend against rising exposures to actions by the U.S. Department of Health & Human Services Office of Civil Rights (OCR) and other agencies as well as private law suits.

Federal Disability & Other Laws Prohibit Health Care Provider Discrimination

As a result of its stepped up enforcement of the ADA, Section 504 and other civil rights and nondiscrimination rules, OCR is racking up an impressive list of settlements with health care providers, housing and other businesses for violating the ADA, Section 504 or other related civil rights rules enforced by OCR. While OCR continues to wage this enforcement battle in the programs it administers, the Departments of Justice, Housing & Urban Development, Education, Labor and other federal agencies also are waging war against what the Obama Administration perceives as illegal discrimination in other areas. Along side their own enforcement activities, OCR and other federal agencies are maintaining a vigorous public outreach to disabled and other individuals protected by federal disabilities and other civil rights laws intended to make them aware of and to encourage them to act to enforce these rights. To be prepared to defend against the resulting risk of claims and other enforcement actions created by these activities, health care, housing and other U.S. providers and businesses need to tighten compliance and risk management procedures and take other steps to prepare themselves to respond to potential charges and investigations.

Recent Settlements Highlight Risk

Enforcement of Discrimination & Other Civil Rights Laws Obama Administration Priority Putting Public & Private Providers At Risk

These and other enforcement actions by OCR and other agencies demonstrate the significant increased federal emphasis on the enforcement of federal discrimination laws against private and public health care and housing providers, state and local governments and other businesses under the Obama Administration. In keeping with this renewed emphasis, the DCF settlement is the latest in a series of federal disability, national origin and other discrimination charges and settlements OCR, has brought over the past year against physicians, public and private hospitals, insurers, federally financed housing providers and other parties providing services financed under programs administered by OCR. As the Department of Housing and Urban Development (HUD), the Equal Employment Opportunity Commission (EEOC) and other federal agencies also similarly have increased emphasis in federal discrimination law enforcement during this period, health care providers and other federal program service providers need to be prepared to defend their programs and practices to withstand federal discrimination charges or other investigations by federal agencies, private plaintiffs or both.

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If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see here. About Solutions Law Press

Indictment of 91 Shows Growing Health Care Fraud Enforcement Risk

September 8, 2011

A nationwide takedown by Medicare Fraud Strike Force operations in eight cities resulted in the Department of Justice filing criminal charges against 91 defendants, including doctors, nurses, and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $295 million in false billing, Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius jointly announced the charges on September 7, 2011.

The charges are provide yet another powerful reminder to health care providers, leaders and organizations of the advisability of tightening compliance practices and taking other steps to guard against ever expanding health care fraud exposures. Already a lead federal enforcement priority for more than a decade, HHS recently established the Center for Program Integrity within the Centers for Medicare & Medicaid Services (CMS) to focus on identifying and stopping fraud and acting swiftly to protect beneficiaries.

Charges Announced September 7 Show Strike Force Targeting Fraud Industry Wide

In announcing the most sweeping joint action to date, HHS and Justice Department officials warned that the latest charges demonstrate the willingness and commitment of federal officials to find and prosecute health care fraud throughout the health care industry. The actions are the latest in a series of strong reminders to providers, leaders and others in the health care industry of the need to tighten compliance and risk management to minimize the risk of getting caught up in the Federal government’s ever-tightening health care fraud investigation and enforcement net.

The charges made against the 91 defendants in the indictments announced cover nearly the entire spectrum of healthcare providers for a variety alleged fraudulent schemes. The defendants charged are accused of various health care fraud-related crimes, including conspiracy to defraud the Medicare program, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, physical and occupational therapy, mental health services, psychotherapy and durable medical equipment (DME). HHS and Justice Department Officials warned these latest sweeping charges clearly signal the resolve of the federal government to find and prosecute health care fraud throughout the industry. Learn more details about September here.

According to the Justice Department and HHS, 70 individuals were charged by Strike Force prosecutors in indictments unsealed on September 6 and September 7, 2011 in six cities. The indictments allege a variety of Medicare fraud schemes involving approximately $263.6 million in false billings. As part of takedown operations last week, 18 additional defendants were charged in Detroit and one defendant was charged in Miami in cases unsealed on September 1, 2011, for their alleged roles in Medicare fraud schemes involving approximately $29.4 million in fraudulent claims. Additionally, two individuals are scheduled to appear in court on September 7, 2011 on charges filed on August. 24, 2011, for their roles in a separate $2 million health care fraud scheme. According to the September 7 announcement, this coordinated takedown involved the highest amount of false Medicare billings in a single takedown in Strike Force history.

According to court documents, the defendants located in Miami, Houston, Baton Rouge, Los Angeles and Detroit allegedly participated in a diverse array of schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided. In many cases, indictments and complaints allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided. Collectively, the doctors, nurses, medical professionals, health care company owners and others charged in the indictments and complaints are accused of conspiring to submit a total of approximately $295 million in fraudulent billing. If convicted, the defendants face a broad range of criminal, civil and administrative sanctions including imprisonment, criminal penalties, civil sanctions, federal program disqualification, state licensing board disciplinary action and other consequences.

Charges Part of Ongoing National Anti-Health Care Fraud Campaign

Suspend payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
Impose a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
Terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
Require provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

Act To Manage Risks

For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on OCR Civil Rights rules and enforcement actions. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

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Leave a Comment » | Academic medicine, Affordable Care Act, Anti-KickBack, ASC, Childrens Health Insurance Program, Corporate Compliance, Durable Medical Equipment, Federal Health Center, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health Plans, Hospital, Laws, Medicaid, Medicare, Medicare Advantage, Medicare Fee Schedule, Medicare Prescription Drug Program, Mental Heatlh, Money Laundering, OIG, Outpatient, Patient Protection and Affordable Care Act, Pharmacy, Physician, Prescription Drugs, Public Policy, Reimbursement, Rural Health Care, Stark, Substance Abuse | Tagged: Health Care Fraud, HEAT, Medicaid Fraud, Medicare, Medicare Fraud, Medicare Fraud Task Force | Permalink
Posted by Cynthia Marcotte Stamer

5/18 Deadline to Register For 5/19 CMS Provider Call on Medicare and Medicaid EHR Meaningful Use Incentive Programs

May 17, 2011

Wish you knew more about how to use electronic health records (EHRs) to earn incentive payments from the Centers for Medicare & Medicaid Services (CMS)? CMS plans to host a national provider education call to help you learn more about meaningful use on Thursday, May 19 at 2:30 p.m. EDT. During the call, CMS plans to discuss:

The definition of meaningful use
The requirements for Stage 1 of meaningful use (2011 and 2012)
How to attest to having met meaningful use
Overview of the meaningful use objectives specification sheets
- Stage 1 EHR Meaningful Use Specification Sheets for Eligible Professionals
- Stage 1 EHR Meaningful Use Specification Sheets for Eligible Hospitals
Q&A about meaningful use

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation. Registration will close at 2:30 p.m. EDT on May 18, 2011, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time. In order to register, you should:

Visit the registration page.
Fill in all required information and click “Register.”
You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter. Please save this page in case your server blocks the confirmation emails. (If you do not receive the confirmation email, check your spam/junk mail filter as it may have been directed there.)
If assistance for hearing impaired services is needed, please email medicare.ttt@palmettogba.com no later than three business days before the call.

Prior to the call, presentation materials will be made available in the “Upcoming Events” section of the Spotlight page on the CMS EHR website.

Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Sixty-two Regional Extension Centers (RECs) across the nation are prepared to offer customized, on-the-ground assistance for eligible professionals and hospitals registering for the CMS EHR Incentive Programs. To locate an REC near you, visit http://www.healthit.

In addition to the May 10 call, recordings of various other recent health information privacy and data security training offered by agencies within the Department of Health and Human Services also now is avaialble on the web. For instance, the National Institute of Standards and Technology (NIST) and the Office for Civil Rights (OCR) are making presentations from the 4th annual conference on “Safeguarding Health Information: Building Assurance through HIPAA Security” co-hosted in Washington, D.C. on May 10 & 11, 2011 available on line for review. The training is part of a series of continuing efforts by the agencies to outreach to various parties on the Privacy and Security Rules of the Health Insurance Portability & Accountability Act of 1996, as amended (HIPAA). Meanwhile, OCR’s Susan McAndrew on Monday shared insights on OCR’s HIPAA regulatory and enforcement agenda at a teleconference to be hosted by the American Bar Association Joint Committee on Employee Benefits at Noon Central on May 16, 2011. Recordings of these presentations are or will be accessible on the sponsoring organizations from their websites. For details about reviewing the May 10-11 presentations, see the 2011 HIPAA Conference website here. For details about the May 16 teleconference, see here.

For Help With Monitoring Developments, Compliance, Investigations Or Other Needs

If you need assistance monitoring federal health reform, policy or enforcement developments, or to review or respond to these or other health care or health IT related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. On May 3, 2011, Ms. Stamer served as the appointed scribe for the ABA Joint Commitee on Employee Benefits Agency meeting with OCR and will moderate a teleconference featuring comments by OCR’s Susan McAndrew for the Joint Committee on Employee Benefits scheduled for May 16. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | Academic medicine, ASC, DEA, Disease Management, DME, Doctor, Electronic Health Records, Electronic Medical Records, Employer, Genetic Information, GINA, Health Care Provider, Health IT, Health Plan, HIPAA, HITECH Act, Hospital, Medicaid, Medicare, Medicare Advantage, Medicare Fee Schedule, Mental Heatlh, OCR, Physician | Tagged: Health Care, HIPAA, Medical Confidentiality, OCR< Privacy, Security | Permalink
Posted by Cynthia Marcotte Stamer

OCR/NIST Share Training Online, OCR’s McAndrew To Speak On May 16 Teleconference

May 10, 2011

The National Institute of Standards and Technology (NIST) and the Department of Health and Human Services (HHS), Office for Civil Rights (OCR) are making presentations from the 4th annual conference on “Safeguarding Health Information: Building Assurance through HIPAA Security” co-hosted in Washington, D.C. on May 10 & 11, 2011 available on line for review. The training is part of a series of continuing efforts by the agencies to outreach to various parties on the Privacy and Security Rules of the Health Insurance Portability & Accountability Act of 1996, as amended (HIPAA). Meanwhile, OCR’s Susan McAndrew is scheduled to share insights on OCR’s HIPAA regulatory and enforcement agenda at a teleconference to be hosted by the American Bar Association Joint Committee on Employee Benefits at Noon Central on May 16, 2011.

The Security Rule sets federal standards to protect the confidentiality, integrity and availability of electronic protected health information by requiring HIPAA covered entities and their business associates to implement and maintain administrative, physical and technical safeguards. Presentations cover a variety of current topics including updates on HHS health information privacy and security initiatives, OCR’s enforcement of health information privacy and security activities, integrating security safeguards into health IT and security automation, insider threat trends and safeguards, and more.

The conference is designed to explore the current health information technology security landscape and the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, the agencies share their practical strategies, tips and techniques for implementing the HIPAA Security Rule.

For details about reviewing the May 10-11 presentations, see the 2011 HIPAA Conference website here. For details about the May 16 teleconference, see here.

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ONC Touts Research On Health IT Benefits In Health Affairs Article

March 20, 2011

Researchers from the Office of the National Coordinator for Health Information Technology (ONC) and other Department of Health & Human Services (HHS) leaders are touting new studies they say show the benefits of investing in health information technology (health IT).

Under the Health Information Technology for Economic and Clinical Health Act (HITECH), part of the American Recovery and Reinvestment Act of 2009, as much as $27 billion Medicare and Medicaid incentive payments will be available to eligible professionals, eligible hospitals, and critical access hospitals when they adopt certified EHR technology and successfully demonstrate “meaningful use” of the technology in ways that improve quality, safety, and effectiveness of patient-centered care.

On March 8, 2011, ONC researches reported results of a comprehensive review of recent studies it says show the effects of health IT on key aspects of health care on the ONC website and in Health Affairs.

According to Donald Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services, the study supports the investments that the HITECH Act makes in health IT. “These new findings are very significant in helping to confirm that our Nation has made the right choice in moving aggressively toward adoption of health information technology,” said Dr. Berwick. “These new findings are very significant in helping to confirm that our Nation has made the right choice in moving aggressively toward adoption of health information technology.”

The review included articles published from July 2007 up to February 2010, following up on earlier reviews of articles from 1995 to 2004 and from 2004 to 2007. This latest review initially surveyed more than 4,000 peer-reviewed articles, of which 154 were found qualified for the parameters of the study, a number similar to the previous efforts. In addition to quality and efficiency of care, the authors categorized additional outcomes including access to care, preventive care, care process, patient safety, and provider or patient satisfaction.

According to the authors, a current review of 154 peer-reviewed studies from July 2007 to February 2010 found:

More than 92 percent reached positive overall conclusions on the effects of health IT;
30 percent found mixed but predominantly positive results; and
Ten articles were found to have negative or mixed-negative results.

ONC reports that the review also reflected a new balance of evidence between HIT “leader” organizations and other entities, especially smaller medical practices. In previous years, much evidence has come from the “leaders.” The current review shows increased evidence of benefits for others as well.

Examples of positive results highlighted by ONC in its reports include:

One study found that at three New York City dialysis centers, patient mortality decreased by as much as 48 percent while nurse staffing decreased by 25 percent in the three years following implementation of electronic health records (EHRs).
In an inpatient study, a clinical decision support tool designed to decrease unnecessary red blood cell transfusions reduced both transfusions and costs, with no increase in patient length-of-stay or mortality.
Another study addressing HIT in 41 Texas hospitals found that hospitals with more advanced HIT had fewer complications, lower mortality and lower costs than hospitals with less advanced HIT.

ONC researchers report that negative findings in the study were most often associated with provider or staff satisfaction related to difficulties in the process of transitioning from paper-based to electronic-based records and care. The researchers conclude these findings “highlight the need for studies that document the challenging aspects of implementing HIT more specifically and how these challenges might be addressed,” such as through strong leadership or staff participation when adopting and implementing HIT.

Reflecting on the findings, Surgeon General Regina Benjamin, M.D., said, “My own personal experience in switching my practice from paper to EHRs showed that the change requires some initial effort; however, it did not interrupt work flow in the clinic. The results are better care for patients and new opportunities for the physician and staff to improve quality outcomes.” Dr. Benjamin switched to EHRs in her Gulf Coast Alabama family practice after two hurricanes and a fire destroyed the clinic’s paper records.

At the Agency for Healthcare Research and Quality, where research into health informatics has been supported since 1968, agency Director Carolyn Clancy, M.D., called attention to the importance of rapid information feedback and current evidence as the Nation pursues HIT implementation. “As we have known, and this new review of the available literature shows, HIT holds tremendous potential to improve health care quality. It is important that we continue to use experience from the field and scientific evidence to guide our efforts to improve the quality and safety of health care for all Americans.”

For Help With Monitoring Developments, Compliance, Investigations Or Other Needs

If you need assistance monitoring federal health reform, policy or enforcement developments, or to review or respond to these or other health care or health IT related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns/ She also regularly designs and presents risk management, compliance and other training for health care providers, professional associations and others including highly popular programs on “Sex Drugs & Rock ‘N Role: Managing Personal Misconduct in Health Care,” “Managing Physician Performance” and others.. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | DME, Doctor, E-Prescribing, Electronic Health Records, Electronic Medical Records, Federal Health Center, Health Care, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health IT, Health Plan, Health Plans, HITECH Act, Hospital, Hospital, Laws, Meaningful Use, Medicaid, Medicare, Medicare Advantage, Physician, Public Policy, Reimbursement | Tagged: EHR, Electronic Health Records, Electronic Medical Records, EMR, Health Care, Health IT, Health Technology, Heatlh Care Reform, HITECH Act, ONC | Permalink
Posted by Cynthia Marcotte Stamer

CMS Finalizes Allotments To States To Pay Medicaid Part B Premiums For Qualifying Individuals

March 19, 2011

Charts showing the final allotments made by the Centers for Medicare & Medicaid Services (CMS) to States of funds to use to pay the Medicare Part B premiums for Qualifying Individuals (QIs) for the Federal fiscal year (FY) 2010 and the preliminary QI allotments for FY 2011 appear in the March 19, 2011 Federal Register.

The funds allotted are funds authorized by Congress pursuant to Section 111 of the Medicare Improvements for Patients and Providers Act of 2008, (MIPPA), Section 2 of the QI Program Supplemental Funding Act of 2008 (the SFA), Section 5005 of the American Recovery and Reinvestment Act of 2009 (ARRA), the “Emergency Aid to American Survivors of the Haiti Earthquake Act” (Haiti Earthquake Act). The final QI allotments for payment of Medicare Part B premiums for FY 2010 are effective October 1, 2009. The preliminary QI allotments for FY 2011 are effective October 1, 2010.

Review the charts here.

For Help With Monitoring Developments or With Compliance, Investigations, Training Or Other Needs

If you need assistance monitoring federal health policy or enforcement developments, or to review or respond to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies, to health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. She also regularly designs and presents risk management, compliance and other training for health care providers, payers, employers, professional associations and others. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | Academic medicine, Affordable Care Act, Childrens Health Insurance Program, Health Care, Health Care Finance, Health Care Reform, Health Plans, Laws, Medicaid, Medicare, Medicare Fee Schedule, Patient Protection and Affordable Care Act, Public Policy | Tagged: Affordable Care Act, ARRA, CMS, Health Care Reform, Medicaid, Medicare, Medicare Part B, Premium Subsidies, Qualitying Individuals | Permalink
Posted by Cynthia Marcotte Stamer

States Get More Info On Affordable Care Act Medicaid Eligibility Maintenance Of Effort; Payers & Providers Must Monitor

March 7, 2011

On February 27, 2011, Department of Health and Human Services Secretary Kathleen Sebelius issued a new letter and a frequently asked questions (FAQ) document that explain Medicaid and Children’s Health Insurance Program (CHIP) provisions in the Affordable Care Act in ways that afford greater flexibility to States. The new guidance clarifies aspects of the maintenance of effort (MOE) rules for Medicaid and CHIP. According to HHS, added guidance will follow. In these turbulent financial times, states are likely to welcome guidance that allows them more flexibility. While HHS and the states work out the detaails of these rules, health care providers and health plans also must keep a close eye out for developments that may require changes in enrollment or coverage coordination procedures to ensure their ability to comply with these evolving requirements.

The Medicaid MOE provision in the Affordable Care Act generally ensures that States’ eligibility rules for adults under the Medicaid program remain in place pending implementation of eligibility rules changes that become effective in January 2014. The MOE provision for children extends to 2019.

The letter and supporting FAQ document released February 27, 2011 address three aspects of the MOE provisions:

The MOE exemption for higher-income adult populations in States that are experiencing budget deficits. Under the Affordable Care Act, if a State has or projects a budget deficit, the MOE provision does not apply to adults who are not eligible for coverage on the basis of pregnancy or disability and whose incomes are above 133 percent of the Federal poverty level. The FAQ document explains State options and how States can seek this exemption.
The implication of the MOE provision on Section 1115 demonstration projects. Some States cover groups of people under Medicaid through a Section 1115 demonstration. As explained in the FAQ document, the MOE provision generally applies to these waivers and demonstrations. However, waivers and demonstration are, by their terms, time limited. The guidance clarifies that the MOE provision does not require States to seek a new or renewed waiver after the expiration of their waiver or demonstration.
How premiums are treated under the MOE requirements. Because premiums and premium increases have an impact on eligibility, previous guidance under the Recovery Act explained that new or increased premiums were considered to be a violation of the Recovery Act MOE requirement. Because the period during which the Affordable Care Act MOE provisions apply is considerably longer than the MOE period under the Recovery Act, this new guidance offers States additional flexibility relating to premiums and the MOE requirements under the Affordable Care Act. This will help a number of States that have been requesting the ability to adjust premiums for populations such as children in CHIP with family incomes above 150 percent of the Federal poverty line.

For Help With Compliance, Investigations Or Other Needs

If you need assistance responding to or monitoring changes in Medicaid, CHIP or other federal or state health program eligibility rules or dealing with other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies and to respond to OCR, FTC, medical board and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on Medicare quality and other compliance concerns. Her publications and insights on HIPAA and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

1 Comment | Affordable Care Act, Childrens Health Insurance Program, Discrimination, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Hospital, Medicaid, Medicare Fee Schedule, Patient Protection and Affordable Care Act, Physician, Reimbursement | Tagged: CHIP, CMS, cooridnation of benefits, Health Care Provider, Health insurer, Health Plans, Hospital, Medicaid, Patient Protection and Affordable Care Act, Physician, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

HHS Imposes 1st HIPAA Privacy Civil Penalty of $4.3 million

February 22, 2011

Health Care Providers Should Strengthen HIPAA Compliance & Defenses As Risks Rise

$4.3 million is the amount of the civil monetary penalty (CMP) that the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has ordered Cignet Health of Prince George’s County, Md., (Cignet) to pay for violating the Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule.

The first CMP ever assessed by OCR under the HIPAA Privacy Rule, the Cignet CMP assessment is the latest in a series of developments documenting the rising risks that health care providers, health plans, health care clearinghouses and their business associates (“covered entities”) face for violations of HIPAA. Covered entities and their business associates should tighten privacy policies, breach and other monitoring, training and other practices to mitigate against exposures in light of recently tightened requirements and new enforcement risks. Read more details.

Even before the announcement of the Cignet CMP, the HIPAA Privacy exposures of covered entities for failing to comply with HIPAA already had risen significantly. As of January 1, 2011, OCR reports that 12,781 of the cases it has investigated have been resolved by requiring changes in privacy practices and other corrective actions by the covered entities and has referred more than 484 Privacy Rule breach investigations to the Department of Justice for consideration for potential criminal prosecution.

While OCR had not assessed any civil monetary penalties against any covered entity for violation of HIPAA before Cignet, OCR’s collection of $2.25 million from CVS Pharmacy, Inc. under a 2009 Resolution Agreement and $100,000 from Providence Health & Services under a 2008 Resolution Agreement demonstrated the willingness of OCR to pursue significant civil remedies against covered entities that it determined willfully violated the Privacy Rules.

In response to these expanding exposures, covered entities and their business associates should review the adequacy of their current HIPAA Privacy and Security compliance policies, monitoring, training, breach notification and other practices taking into consideration the Cignet, Provident and CVS enforcement actions, emerging litigation and other enforcement data.; their own and reports of other security and privacy breaches and near misses, and other developments to determine if additional steps are necessary or advisable.

For Help With Compliance, Investigations Or Other Needs

If you need assistance auditing or tightening your existing HIPAA and other confidentiality practices or addressing other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer medical privacy and other compliance and risk management policies and to respond to OCR, FTC, medical board and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on Medicare quality and other compliance concerns. Her publications and insights on HIPAA and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | Academic medicine, ARRA, ASC, Centers For Disease Control, Disease Management, DME, Doctor, E-Prescribing, Electronic Health Records, Electronic Medical Records, Federal Health Center, Genetic Information, Health Care, Health Care Provider, Health Care Quality, Health IT, Health Plans, HIPAA, HITECH Act, Hospital, Hospital, Indian Health, Medicaid, Medical Licensure, Medicare, Medicare Advantage, Medicare Fee Schedule, Mental Heatlh, OCR, Peer Review, Pharmacy, Physician, Privacy, Reimbursement, Telemedicine | Tagged: covered entity, Health Care, HIPAA, Hospital, Medical Confidentiality, OCR, Physician, Privacy Rule, Security Rule | Permalink
Posted by Cynthia Marcotte Stamer

ONC Giving Small Critical Access And Rural Hospitals Added Electronic Health Records Funds

February 9, 2011

Dr. David Blumenthal, MD, MPP, national coordinator for health information technology in the Office of the National Coordinator for Health Information Technology (ONC) announced that ONC’s Regional Extension Center (REC) program will make available an additional $12 million in new technical support assistance to help critical access hospitals (CAHs) and rural hospitals adopt and become meaningful users of certified health information technology to provide a wide range of support services.

The new funds are intended to help the 1,777 critical access and rural hospitals in 41 states and the nationwide Indian Country, headquartered in the District of Columbia qualify for substantial EHR incentive payments from Medicare and Medicaid. For a listing of the award recipients for the grants announced today, see here. The intent of this supplement is to provide additional technical support to critical access and rural hospitals with fewer than 50 beds in selecting and implementing EHR systems primarily within the outpatient setting. This funding is in addition to the $20 million provided to RECs in September 2010 to provide technical assistance to the CAHs and Rural Hospitals.

The new funding is provided under the Health Information Technology Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009. The HITECH Act created the Medicare and Medicaid EHR incentive programs, which will provide incentive payments to eligible professionals, eligible hospitals, and CAHs that adopt and demonstrate meaningful use of certified EHR technology. Incentives totaling as much as $27.4 billion over 10 years could be expended under the program, which is administered by the Centers for Medicare & Medicaid Services. In addition, the HITECH Act provided $2 billion through ONC to support technical assistance, training, and demonstration projects to assist in the nation’s transition to EHRs.

The additional CAHs and rural hospital funding will be administered through ONC’s Regional Extension Center (REC) program. The RECs are specifically designed to offer a wide range of hands-on technical assistance, guidance, and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of certified EHRs under the Medicare and Medicaid incentives programs. A total of 62 RECs are located throughout the country. This additional funding is being awarded 48 RECs serving CAH and rural hospitals provides in 41 states and the nationwide Indian Country.

Today’s $12 million round of awards will result in a total of approximately $32 million of funding provided to the RECs to support CAH health IT adoption.

A complete listing of REC grant recipients and additional information about the Health Information Technology Regional Extension Centers, see here.

For information about the Medicare and Medicaid EHR Incentive Programs, see here.

For More Information Or Assistance

If you need assistance with meaningful use or other EMR or other health technology, risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients to establish and administer compliance and risk management policies and to respond to DEA and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns. A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns including a number of programs and publications on Medicare quality and other compliance concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

About Solutions Law Press

Leave a Comment » | Electronic Health Records, Evidence Based Medicine, Health Care, Health Care Finance, Health Care Quality, Health Care Reform, Health IT, Hospital, Indian Health, Meaningful Use, Medicaid, Medicare, Rural Health Care | Tagged: AARA, Affordable Care Act, Critical Access Hospital, electronic health record, electronic medial record, Health Care Reform, Meaningful Use, ONC, rural hospital | Permalink
Posted by Cynthia Marcotte Stamer

Health Care Fraud Enforcement Packs New Heat

December 16, 2010

As part of ongoing efforts to prevent and fight health care fraud, US Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder today announced that the Centers for Medicare and Medicaid Services (CMS) plans to acquire and new state-of-the-art predictive modeling fraud fighting analytic tools to prevent wasteful and fraudulent payments in Medicare, Medicaid and the Children’s Health Insurance Program before they occur As Sebelius and Holder made the announcement at a Fraud Prevention Summit held at the University of Massachusetts in Boston, CMS issued a solicitation for state-of-the-art fraud fighting analytic tools to help the agency predict and prevent potentially wasteful, abusive or fraudulent payments before they occur. These actions come as CMS and the Justice Department are touting record recoveries from already ongoing enforcement actions.

CMS intends to use these new tools into the National Fraud Prevention Program and to complement and expand fraud detection and enforcement work and practices utilized by the joint HHS and Department of Justice Health Care Fraud Prevention and Enforcement Action Team (HEAT) in recent years.

CMS is already starting to take administrative action to stop payments in various pilot programs or other anti-fraud initiatives. The move to acquire and use additional predictive model tools comes as CMS is implementing new and expanded health care fraud detection and enforcement authority provided in the Patient Protection and Affordable Care Act (Affordable Care Act). CMS and the Justice Department are moving aggressively to take advantage of these new powers and resources. In recent months HHS founded the new Center for Program Integrity within CMS would focus on identifying and stopping fraud and acting swiftly to protect beneficiaries. It also proposed new rules implementing enhanced health care fraud investigation and enforcement powers enacted as part of the Affordable Care Act.

Meanwhile, CMS and the Justice Department have continued to aggressively investigate and prosecute suspected health care fraud. Already, stepped up fraud enforcement efforts have produced significant recoveries. In Fiscal Year 2010, the Department of Justice obtained settlements and judgments of more than $2.5 billion in False Claims Act matters alleging health care fraud. This is more than ever before obtained in a single year, up from $1.68 billion in Fiscal Year 2009.

In light of these developments, health care providers should tighten billing and other compliance practices and monitoring of enforcement and other oversight activities by CMS and the Justice Department. Get more details here.

For Assistance

Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising physicians, hospitals and other health industry clients about regulatory compliance and enforcement, quality assurance, peer review, licensing and discipline, and other medical staff performance matters. She continuously advises health industry clients about the use of technology, process and other mechanisms to promote compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational needs. As part of this experience, she has worked extensively with health care providers, payers, health care technology and consulting and other health industry clients, as well as other businesses, on privacy, data security, trade secret and related matters. A popular lecturer and widely published author on health industry concerns, Ms. Stamer also publishes and speaks extensively on health care compliance, staffing and human resources, compensation and benefits, technology, medical staff, public policy, reimbursement, privacy, technology, and other health and managed care industry regulatory, and other operations and risk management concerns for medical societies and staffs, hospitals, the HCCA, American Bar Association, American Health Lawyers Association and many other health industry groups and symposia. Her highly popular and information packed programs include many highly regarded publications on HIPAA, FACTA, medical confidentiality, state identity theft and privacy and other many other related matters. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. To review some of her many publications and presentations, or for additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. You can review other recent health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. 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 at here or e-mailing this information here. To unsubscribe, e-mail here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here. For important information concerning this communication click here.

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Posted by Cynthia Marcotte Stamer

12/15 Deadline For Input on New Joint Commission Heart Failure Certification

December 2, 2010

December 15, 2010 is the deadline to share your comments with the Joint Commission on proposed requirements for Advanced Certification in Heart Failure from health care professionals who care for individuals with heart failure.
The Joint Commission drives much of how hospitals and a growing number of health care providers are judged and ultimately paid. Since the cost of meeting these standards ultimately will be passed on in the charges made by health care providers, health plans and employers should evaluate these credentials and provide appropriate comments when the demonstrated benefits of added conditions or paperwork drive up costs unnecessarily, divert resources from more important patient care goals, or promote other inefficiencies.

The Joint Commission is a leading quality accreditation agency, whose reach now extends to almost all health care organizations and providers. While acknowledging that the Joint Commission has and continues to do much to promote health care quality, health care providers increasingly complain the Joint Commission requirements increasingly are becoming overkill that unnecessarily adds costs and recordkeeping burden in a way that puts measurement before patient care, but feel pressure to comply. Supporters say the standards are necessary to maintain and demonstrate quality.

Striking the proper balance between quality and cost is at the heart of much of the current national initiative to control costs, as well as the efforts of almost all health care providers and payers. To promote proper standards, share comments before the standards are adopted. In the meanwhile, what is your experience about the Joint Commission and the impact of their growing involvement in health care?

The Joint Commission is expanding its Advanced Heart Failure Certification program to encompass the care provided to individuals with heart failure in outpatient settings. The Joint Commission and the American Heart Association (AHA) have established a strategic alliance to recognize programs that demonstrate excellence in the care of individuals with heart failure in both inpatient and outpatient care settings. To receive this certification, an organization must demonstrate compliance with Joint Commission standards, including use of the American Heart Association’s Get With The Guidelines®, and ongoing performance improvement. This new advanced certification is projected to launch in July 2011.

For More Information or Assistance

For a link to the proposed standards or other information, see here. If you need help evaluating or responding to this development of other health care reimbursement, technology and process, compliance, risk management, transactional, operational, enforcement or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, cstamer@Solutionslawyer.net.
Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 23 years experience advising health industry clients about these and other matters. She continuously advises health industry clients about the use of technology, process and other mechanisms to promote compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational needs. As part of this experience, she has worked extensively with health care providers, payers, health care technology and consulting and other health industry clients on the design and use of health information systems, technology, privacy and other related. A popular lecturer and widely published author on health industry concerns, Ms. Stamer also publishes and speaks extensively on health care privacy, technology, and other health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. To review some of her many publications and presentations, or for additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

About Solutions Law Press

Leave a Comment » | Consumer Driven Health Care, Disease Management, DME, Doctor, Evidence Based Medicine, Health Care, Health Care Finance, Health Care Provider, Health Care Quality, Hospital, Medicaid, Peer Review, Reimbursement | Tagged: Cardiology, Certification, Health Care, Heart, Joint Commission, outpatient, Wellness | Permalink
Posted by Cynthia Marcotte Stamer

OIG Shares Key Insights On When Owners, Officers & Managers Face OIG Program Exclusion Based On Health Care Entity Misconduct

October 21, 2010

The Department of Health & Human Services Office of Inspector General (OIG) this morning (October 21, 2010) posted to its website key guidance about when OIG will exercise its authority under the permissive exclusion rules of Social Security Act (Act) § 1128(b)(15)(A)(ii) to exclude from Federal health program participation owners, officers or managing employees of health care organizations based on their role, involvement or ownership interest in a health industry company convicted of certain offenses or excluded from Federal health program participation.

The Guidance For Implementing Permissive Exclusion of Authority under Section 1128(b)(15) of the Social Security Act (Guidance) provides valuable insights for health care organizations, their owners, officers and managers about how OIG expects them to act and the evidence that OIG likely will require should OIG bring an OIG exclusion action against them personally following the conviction or OIG exclusion of their health care organization for misconduct. To position themselves to survive OIG or related exclusion or prosecution, health care organizations and their owners, officers and management use the Guidance as a guide to help strengthen the defensibility of their daily actions against potential OIG scrutiny and consider the advisability of updating their personal and organizational practices, policies and leadership training in response to this Guidance.

The Guidance discusses the guiding principles and core factors and presumptions that OIG generally will apply to decide if the OIG will should exclude an individual from Federal health program participation based on the involvement of the individual as an owner, officer or manager of company that has been excluded from Federal program participation or convicted of certain health care crimes.. Because these OIG has identified these factors as core considerations in its exclusion analysis, the Guidance provides invaluable guidance for health care entities, their owners, officers and management employees about opportunities position their conduct for defensibility against OIG enforcement exposures. Consequently, owners, officers and managers alike concerned about their exposure to Federal program exclusion or other personal liability under Federal health care fraud laws should use the Guidance to help strengthen their ability to avoid personal exclusion or other prosecution by the OIG as a result of their involvement with a health care organization excluded from Federal program participation or convicted of other crimes. For a more detailed discussion of the Guidance, see here

For More Information or Assistance

If you need assistance evaluating or responding to this development of other health care compliance, risk management, transactional, operational, reimbursement, enforcement or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, cstamer@Solutionslawyer.net.

Other Resources

We hope that this information is useful to you. If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

About Solutions Law Press

You can review other recent health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. 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 at here or e-mailing this information here.

Leave a Comment » | ASC, Centers For Disease Control, Childrens Health Insurance Program, Conditions of Participation, Corporate Compliance, Disability Discrimination, DME, Doctor, E-Prescribing, false claims act, Federal Health Center, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Hospital, Hospital, Indian Health, Medicaid, Medicare, Medicare Advantage, Medicare Fee Schedule, Medicare Fee Schedule, Mental Heatlh, Money Laundering, OIG, Outpatient, Physician, Prescription Drugs, Reimbursement, Rural Health Care, Stark | Permalink
Posted by Cynthia Marcotte Stamer

CMS Delegated Lead Responsibility For Development of New Affordable Care Act-Required Medicare Self-Referral Disclosure Protocol

October 15, 2010

The Centers for Medicare & Medicaid Services (CMS) has been assigned responsibility for the development of the Medicare self-referral disclosure protocol required by Section 6409(a) and (b) of the Patient Protection and Affordable Care Act (ACA), Public Law 111–148, and the rules governing when HHS will exercise its discretion under Section 1877(g) of the Social Security Act to reduce sanction otherwise due and owing by provider for engaging in self-referral violations. Health & Human Services (HHS) Secretary Kathleen Sebelius announced her delegation of responsibility for the development of these new programs to the Administrator of CMS in the October 15, 2010 Federal Register here.

Under ACA Section 6402, Medicare providers and suppliers generally must report and return Medicare overpayments by the later of:

60 days after the date on which the overpayment was identified; or
The date any corresponding cost report is due, if applicable.

To encourage providers to self-disclose self-referral violations, however, Section 6409 of ACA dictates that HHS in cooperation with its Inspector General establish a Medicare self-referral disclosure protocol (SRDP) that Medicare providers may use to self-disclose actual or potential violations of the physician self-referral prohibitions of Section 1877 of the Social Security Act. Where a Medicare provider or supplier electronically submits a disclosure in accordance with the SRDP and receives email confirmation of receipt of the disclosure from CMS, the provider’s otherwise applicable obligation to return a potential overpayment within 60 days under ACA Section 6402 will be tolled until:

CMS and the provider enter into a settlement agreement;
The provider withdraws from the SRDP, or
CMS removes the provider of services or supplier from the SRDP.

In addition to delaying the deadline for returning overpayments, ACA also includes timely self-disclosure as one of the criteria that HHS can take into account when deciding whether to exercise its discretion to abate sanctions for violation of the self-referral prohibition. Unfortunately, Section 6409(a)(3) of ACA also expressly requires that the SRDP be distinct and separate from the advisory opinion process under 42 C.F.R. §§ 411.370 through 411.389. As a consequence, Medicare providers concerned about potential exposure under the self-referral rules generally should not expect to be allowed to seek protection under the SRDP while simultaneously seeking an advisory opinion for conduct underlying the same arrangement.

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers and other health industry clients to respond to these and other health care industry enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly speaks and conducts training on and other health industry compliance, management and operations matters. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Meanwhile, Section 6409(b) of the ACA grants HHS authority to reduce the amount of sanctions owing for all violations of the physician self-referral statute. In establishing the amount by which an overpayment resulting from an actual or potential violation(s) may be reduced, the Secretary may consider: the nature and extent of the improper or illegal practice; the timeliness of such disclosure; the cooperation in providing additional information related to the disclosure; and such other factors as the Secretary considers appropriate.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. If you need assistance evaluating or responding to the Health Care Reform Law or health care compliance, risk management, transactional, operational, reimbursement, or public policy concerns, please contact the author of this update, Cynthia Marcotte Stamer, at (469) 767-8872, cstamer@Solutionslawyer.net.

Leave a Comment » | Anti-KickBack, Health Care, Health Care Provider, Hospital, Medicaid, Medicare, Reimbursement | Tagged: Affordable Care Act, Health Care Fraud, Medicare, self-referral, self-referral disclosure protocol | Permalink
Posted by Cynthia Marcotte Stamer

HHS announces Rules Implementing Tools Added By Affordable Care Act to Prevent Federal Health Program Fraud

September 22, 2010

The U.S. Department of Health and Human Services (HHS) proposed new rules it hopes to strengthen its efforts to help identify and fight waste, fraud and abuse in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The rules implementing a series of provisions designed to fight fraud in the health care system enacted as part of the Affordable Care Act follow on the heels of HHS’ announcement of the Center for Program Integrity within the Centers for Medicare & Medicaid Services (CMS) focused on identifying and stopping fraud and acting swiftly to protect beneficiaries. Given the expanded powers to suspend program eligibility and other risks providers will face under these new rules, all health care providers participating in any of these federal programs should both review and strengthen their compliance efforts and practices and share any concerns in response to the proposed rules.

Among other things, the proposed rule will:

Define requirements for suspending payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
Establish CMS authority for imposing a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
Outline requirements for states to terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
Solicit input on how to best structure and develop provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

Health care providers and others likely to be affected by these proposed rules should evaluate the proposals and act quickly to share input on any areas of concern as they prepare to strengthen their processes in response to the new rules and tools.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

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Leave a Comment » | Conditions of Participation, Health Care Finance, Health Care Fraud, Health Care Provider, Medicaid, Medicare, Medicare Advantage, Physician, Physician Licensing | Tagged: Affordable Care Act, CHIP, False Claims, Health Care, Health Care Fraud, Medicaid, Medicare | Permalink
Posted by Cynthia Marcotte Stamer

OIG: Texas Overbilled Medicaid for Medical Transportation Costs

September 5, 2010

The Department of Health & Human Services Office of Inspector General (OIG) estimates that Capital Area Rural Transit System received overpayments of at least $583,000 ($292,000 Federal share) for nonemergency medical transportation claims that did not comply with Federal and State requirements in 2007. The audit also identified other questionable claims, which are targeted for added review. The reported findings provide critical insights about some of the practices of Medicaid transportation services providers that are likely to draw audit or enforcement attention by OIG or other federal or state officials.

According to the “Review Of Nonemergency Medical Transportation Costs In The State Of Texas (Transportation Provided By Capital Area Rural Transit System,” Report Number a-06-08-00096 (the “Audit Report”), the audit found concerns in 68% of 100 audited samples of Medicaid billings of Capital Area Rural Transportation System (CARTS).for non-emergency services provided to Medicaid beneficiaries during 2007 as a subcontractor to the State of Texas. Texas Health and Human Services Commission contracted with the Texas Department of Transportation (TxDOT) to administer the nonemergency medical transportation to and from covered health care service providers for Medicaid beneficiaries and other eligible recipients. TxDOT subcontracted with CARTS to provide these transportation services to 10 Texas counties. Read More Details.

For More Information or Assistance

If you need assistance reviewing and updating your existing practices in response to this or other OIG, CMS or other federal or state Medicaid, Medicare or other audit or enfocement activities or with other health industry regulatory, reimbursement or other operational or compliance concerns, please contact the author of this update, attorney Cynthia Marcotte Stamer. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients with licensure, contracting, reimbursement, compliance, public policy, regulatory, staffing, public policy and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on these and other compliance, management and operations matters. You can contact Ms. Stamer to inquire about engaging her services or for information about training or other resources that she provides at (469) 767-8872 or via e-mail here. To get more information about Ms. Stamer and her health industry experience, see here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

About Solutions Law Press

Solutions Law Press™ provides health industry and other risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.

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Posted by Cynthia Marcotte Stamer

Initial EHR Certification Bodies Named

August 30, 2010

The Office of the National Coordinator for Health Information Technology (ONC) today (August 30, 2010) named Certification Commission for Health Information Technology (CCHIT), Chicago, Ill. and the Drummond Group Inc. (DGI), Austin, Texas as the first technology review bodies authorized to test and certify electronic health record (EHR) systems for compliance with the standards and certification criteria that were issued by the U.S. Department of Health and Human Services earlier this year. The announcement comes less than two months after issuance of final meaningful use rules. Read more here.

For More Information or Assistance

If you need assistance responding to the EHR meaningful use, HITECH and other privacy, or other health industry regulatory, reimbursement or other operational or compliance concerns, please contact the author of this update, attorney Cynthia Marcotte Stamer. Ms. Stamer has extensive experience advising and assisting health care providers and other health industry clients with licensure, contracting, reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on these and other compliance, management and operations matters. You can contact Ms. Stamer to inquire about engaging her services or for information about training or other resources that she provides at (469) 767-8872 or via e-mail here. To get more information about Ms. Stamer and her health industry experience, see here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

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Posted by Cynthia Marcotte Stamer

HHS Invites Input On Medicaid Changes To Promote Children’s Health Quality

August 2, 2010

August 30, 2010 is the deadline for interested persons to provide input to Health & Human Services about legislation to improve the quality of care provided to children under Medicaid and the Children’s Health Insurance Program, including recommendations for quality reporting by the States. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires the Secretary of Health and Human Services to provide to Congress recommendations for legislative changes to improve the quality of care provided to children under Medicaid and the Children’s Health Insurance Program. HHS invited public input for use in preparing these recommendations on July 30, 2010 here.

For More Information or Assistance

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers and other health industry clients with licensure, contracting, reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on these and other compliance, management and operations matters. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here. To review the regulations, see here. For a summary, see here.

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Leave a Comment » | Childrens Health Insurance Program, Health Care, Health Care Finance, Health Care Quality, Health Care Reform, Health Plan, Health Plans, Hospital, Indian Health, Medicaid, Physician, Uncategorized | Tagged: children's health, CHIPRA, Health Care, health care quality, HHS, Hospital, Medicaid, Physician, quality reporting, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

CMS & ONC To Co-Host 7/22 ONC Certification & Medicare/Medicaid EHR Incentive Program Audio Training

July 20, 2010

The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) will co-host an Audio Training on the Final Rules for ONC Certification and Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs on July 22, 2010 from 2:00-3:30 pm EST.

During the training, the Agencies plan to discuss:

Benefits of HIT
Summary of the final rules
ONC temporary certification process
ONC initial set of standards and implementation specifications
Medicare and Medicaid EHR Incentives Programs including the initial definition of meaningful Use

To join the audio training, dial 1-877-251-0301 and enter the Conference ID pass code: 87841621

Materials will be made available prior to the training at the following web address here.

For more information about CMS EMR incentives, see here.

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers, health plans and insurers, and other health and insurance industry clients with HIPAA, EMR and other privacy and data security, reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly conducts training on these and other health industry technology, compliance, management and operations matters. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

Leave a Comment » | Affordable Care Act, ARRA, Doctor, E-Prescribing, Electronic Health Records, Genetic Information, GINA, Health Care, Health Care Provider, Health Care Reform, Health IT, Health Plan, Health Plans, HIPAA, HITECH Act, Hospital, Hospital, Meaningful Use, Medicaid, Medicare, Medicare Advantage, OCR, Privacy, Technology, Telemedicine | Tagged: Data Security, EHR, Electronic Health Records, EMR, Health Information Technology, Health IT, Hi-TECH Act, HIPAA, HITECH Act, IT, ONC, ONC Certification, Privacy | Permalink
Posted by Cynthia Marcotte Stamer

CMS Proposes Changes To Civil Monetary Penalty Rules For Nursing Homes

July 12, 2010

August 11, 2010 is the deadline to submit comments on proposed changes to Medicare and Medicaid regulations governing the imposition and collection of civil monetary penalties against nursing homes for failing to comply with Medicare & Medicaid regulations.

The Centers for Medicare & Medicaid Services today (July 12, 2010) proposed regulations that would expand and revise current Medicare and Medicaid regulations regarding the imposition and collection of civil money penalties by CMS when nursing homes are not in compliance with Federal participation requirements in accordance with the Patient Protection and Affordable Care Act of 2010. A copy of the proposed regulations is available for review here.

If you need assistance evaluating, preparing comments, or responding to the proposed regulations or with other health industry matters, please consider contacting the author of this update. Attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care providers and other health industry clients with reimbursement, compliance, public policy, regulatory, staffing, and other operations and risk management matters. Ms. Stamer also regularly publishes and conducts training on health industry compliance, management and operations matters. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

Leave a Comment » | Anti-KickBack, ASC, Conditions of Participation, Corporate Compliance, Doctor, Health Care, Health Care Fraud, Health Care Provider, Health Care Quality, Medicaid, Medicare, Stark | Tagged: Civil Monetary Penalties, CMS, Health Care, Health Care Fraud, Hospitals, Medicaid, Medicare, Nursing Homes, Physicians, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

OIG Touts Expanding Health Care Fraud Enforcement Success & Launches New Health Care Fraud Hotline

May 20, 2010

Continuing expansion of health care fraud enforcement initiatives, the Office of Inspector General (OIG) recently released its Health Care Fraud and Abuse Control Program Report and launched a new online Fraud Hotline Website to allow individuals the option of reporting federal health care fraud suspicions to OIG online.

The May 12 launch of the Fraud Hotline Website means whistleblowers now can report suspected federal health care fraud to OIG over the Internet, by telephone or by mail. CMS hopes the addition of online fraud reporting capability will lead to more investigations, audits and/or monetary recoveries.

OIG followed up May 13, by releasing its latest Health Care Fraud and Abuse Control Program Report, In addition to detailing 2009 healthcare fraud enforcement activities and accomplishments, the Report also highlights the continuing success of its HEAT initiative as well as new enforcement tools created by the recent health care reform legislation, the “Fraud Enforcement and Recovery Act of 2009”(FERA) and other recent developments that facilitate the ability of OIG and the Justice Department to prosecute and secure larger fines and penalties from healthcare providers engaging in health care fraud. For more information, read the OIG Press Release here.

The heightened emphasis by federal officials on enforcement of federal health care fraud laws and the implementation of tools like the new Fraud Hotline Website increase the likelihood both that whistleblowers will turn in health care providers and other individuals and organizations that file false claims in violation of the FCA and the liability that violators may incur for that misconduct. These and other activities are part of a significant ramp up in federal emphasis on the detection and prosecution of violations of federal health care fraud laws by both the Administration and Congress. Many state agencies also are stepping up their health care fraud investigations and enforcement. In light of this new emphasis upon health care fraud detection and enforcement, health care providers now more than ever need to prepare to demonstrate the appropriateness and defensibility of their health care billing and other compliance efforts.

The author of this update, attorney Cynthia Marcotte Stamer, has extensive experience advising and assisting health care practitioners and other businesses and business leaders to establish, administer, investigate and defend health care fraud and other compliance and internal control policies and practices to reduce risk under federal and state health care and other laws. You can get more information about her health industry experience here. If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Ms. Stamer at (469) 767-8872 or via e-mail here.

Other Recent Developments

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

Leave a Comment » | Affordable Care Act, America's Healthy Futures Act, American's Affordable Health Choices Act, Anti-KickBack, ASC, Centers For Disease Control, Corporate Compliance, Durable Medical Equipment, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, HITECH Act, Hospital, Medicaid, Medical Licensure, Medical Malpractice, Medicare, Medicare Advantage, Medicare Prescription Drug Program, Money Laundering, OCR, OIG, Patient Protection and Affordable Care Act, Pharmacy, Physician, Prescription Drugs, Public Policy, Reimbursement, Rural Health Care, Stark, Substance Abuse, Telemarketing, Uncategorized, Veterans Health, Veterans Health Care | Tagged: Health Care Fraud, Health Care Provider, Medicaid, Medicare, OIG | Permalink
Posted by Cynthia Marcotte Stamer

HHS Invites Input on Proposed Strategic Framework on Multiple Chronic Conditions

May 19, 2010

June 18, 2010 is the deadline for interested persons to submit comments to the Office of Public Health and Science of the Department of Health & Human Services (HHS) on the draft “HHS Strategic Framework on Multiple Chronic Conditions” in response to the request for information published here in the May 19, 2010 Federal Register. Interested parties can review the draft strategic framework here.

Approximately 75 million Americans have multiple (2 or more) concurrent chronic conditions, including problems such as hypertension, heart disease, arthritis, diabetes, mental health conditions, and chronic respiratory infections. As these combined morbidities drive significant health costs, HHS through the Office of Public Health and Science (OPHS) and its HHS Interagency Workgroup on Multiple Chronic Conditions has drafted a “Strategic Framework on Multiple Chronic Conditions” to address approaches to improving the health of individuals with concurrent multiple chronic conditions by providing options for HHS to strengthen coordination of its efforts internally and collaboration with stakeholders externally. The strategic framework seeks to improve the foundation for realizing optimum health and quality of life for individuals with multiple chronic conditions. In the request for information published May 19, 2010, HHS is seeking comments from stakeholders and the public on the draft strategic framework.

If you need assistance to submit comments in response to the request for information or with any other health industry regulatory or operational matter, please contact Cynthia Marcotte Stamer at (469) 767-8872 or e-mail her here.

Other Recent Developments

If you found this information of interest, you also may be interested in information about upcoming programs to be presented by Ms. Stamer, acquiring a copy of a recording or materials from previous programs she has presented, or arranging training for your organization. For more information about these opportunities, contact Ms. Stamer directly.

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

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Leave a Comment » | Health Care, Health Care Quality, Medicaid, Medicare, Mental Heatlh, Physician, Reimbursement, Uncategorized, Wellness | Permalink
Posted by Cynthia Marcotte Stamer

DEA/DOJ Release Interim Final E-Prescribing Rules

March 25, 2010

Health care providers wishing to electronically prescribe controlled substance should begin reviewing and updating their practices and technology to comply with requirements of the Interim Final Regulations scheduled for publication in the Federal Register on March 31, 2010. Read details at http://wp.me/ptOGJ-94

An advance copy of the new Interim Final Regulation with Request for Comments released March 24, 2010 by the Drug Enforcement Administration (DEA) and Department of Justice on Electronic Prescribing of Controlled Substance on is posted for review here.

Concurrent with publication of the Interim Final Rule, the DEA is inviting comment on DEA is seeking additional comments on the following issues: identity proofing, access control, authentication, biometric subsystems and testing of those subsystems, internal audit trails for electronic prescription applications, and third-party auditors and certification organizations.

About The Author

If you need assistance with health industry human resources or other management, concerns, wish to inquire about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer at cstamer@solutionslawyer.net or (469) 767-8872.

Nationally and internationally recognized for more than 22 years of work with health industry technology, privacy and data security, regulatory compliance, reimbursement, workforce and staffing, licensure and accreditation, and other quality, risk management, operations and public policy matters organizations, publications, workshops and presentations and leadership Cynthia Marcotte Stamer has worked extensively with physicians, health systems, specialty and other pharmacy, telemedicine and other health technology, and other health industry clients on a diverse range of operational, product and process development, regulatory, licensure, public policy and risk management protections relating to e-prescribing, telemedicine, interoperable and other electronic health and medicine arrangements and other health care internal controls, process and privacy and technology matters. The publisher of the Solutions Law Press Health Care Update, and Solutions Law Press Health Care Privacy & Technology Update, Ms. Stamer also is a popular speaker and author of these and other health industry topics. She regularly publishes, speaks and conducts training for health industry and other organizations, the ABA, American Health Lawyers Association (AHLA), Health Care Compliance Association, Institute of Internal Auditors, various medical society and other professional organizations, the Medical Group Management Association, and many other organizations. Her many publications and programs include“Changing Regulations Will Ease Way for E-Prescribing, But Physicians Shouldn’t Jump the Gun,” “Telemedicine, E-Prescribing & Electronic Health Records: Opportunities & Exposures,” “Telemedicine & E-Prescribing: Evolving Ethical, Licensing & Reimbursement Rules & Realities,” the “Tort & Other Liability” Chapter of the ABA Health Law Section/BNA E-Health & Technology Treatise, “Protecting & Using Patient Data in Disease Management Opportunities, Liabilities and Prescriptions,” Chapter 1: Privacy.” The Quest for Interoperable Electronic Health Records: A Guide to Legal Issues in Establishing Health Information Networks (AHLA 2005) (Contributing Author), “Cybercrime and Identity Theft: Health Information Security beyond HIPAA,” “Privacy & Securities Standards-A Brief Nutshell” and numerous other programs and publications on telemedicine and e-prescribing, HIPAA and other privacy and data security, and other related internal controls and operational matters. Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Spencer Publications, World At Work, SHRM, Business Insurance, James Publishing and many others. You can review other highlights of Ms. Stamer’s health care experience here, and employment experience here. Her insights on these and other matters appear in Managed Care Executive, Modern Health Care, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, MDNews, Kentucky Physician, and many other national and local publications.

Other Resources

If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer including:

For More Information

We hope that this information is useful to you. 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 at here or e-mailing this information here. To unsubscribe, e-mail here.

Leave a Comment » | Centers For Disease Control, Controlled Substances, Corporate Compliance, DEA, Doctor, E-Prescribing, Electronic Health Records, Electronic Medical Records, false claims act, FDA, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health IT, HIPAA, HITECH Act, Hospital, Licensing, Meaningful Use, Medicaid, Medical Licensure, Medicare, Medicare Advantage, Medicare Prescription Drug Program, Pharmacy, Physician, Physician Licensing, Prescription Drugs, Privacy, Reimbursement, Telemedicine | Tagged: Controlled Substances, DEA, E-Prescribing, Health IT, Health Technology, HIPAA, HITECH Act, Meaningful Use, Telemedicine | Permalink
Posted by Cynthia Marcotte Stamer

Medicare Ends Fox Insurance Company Drug Plan Contract As CMS Turns Up Heat on Medicare Advantage & Part D Plan Enforcement & Oversight

March 16, 2010

By Cynthia Marcotte Stamer

The Centers for Medicare & Medicaid Services (CMS) terminated its Medicare Part D prescription drug coverage contract with Fox Insurance Company (Fox) on March 9, 2010. The action highlights CMS’s growing scrutiny and enforcement of Medicare requirements against Medicare Part D, Medicare Advantage Plans and other federal health care program contractors.

CMS terminated the Fox contract after CMS found the failure by Fox’s plan and services to meet Medicare’s requirements to provide enrollees with prescription drugs according to recognized standards of care jeopardized the health and safety of Fox enrollees. When announcing the contract termination, CMS reported that an on-sight review by CMS showed that Fox committed a series of violations, including improperly denying its enrollees coverage of critical HIV, cancer, and seizure medications. CMS issued an enrollment and marketing sanction to Fox on Feb. 26, 2010, because the organization was not following Medicare’s rules for providing prescription drug coverage to its enrollees. According to CMS, an onsite audit conducted between March 2 and March 4 showed that Fox’s problems persisted and that Fox continued to subject its enrollees to obstacles in getting sustaining medicines or other needed medications. Among other things, CMS found Fox:

Failed to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law;
Failed to meet the plan’s appeals deadlines; and
Did not comply with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.
Failed to notify enrollees about prior authorization and step therapy determinations as required by Medicare.

CMS also found that many of the obstacles were in place to limit access to high-cost drugs, which could have led to enrollees’ clinical needs not being met.

In many cases, CMS reported that Fox required enrollees to have unnecessary and invasive medical procedures before they were able to obtain drugs. Finding that Fox was unable to satisfactorily address these compliance concerns and furnish medicines to its Medicare enrollees, CMS immediately terminated the Fox contract.

At the time of the termination, more than 123,000 Medicare beneficiaries were enrolled in Fox plans. Beginning March 10, 2010, CMS indicated that LI-NET, a Medicare run program administered by Humana, would replace the Medicare Part D coverage of enrollees affected by the Fox contract termination on an interim basis. Fox enrollees will be able to choose a new Medicare prescription drug plan through May 1, 2010. Current enrollees who do not choose a plan will be enrolled into a new plan by Medicare. CMS is sending letters explaining the actions taken by CMS to enrollees and has established a 1-800 number to receive questions.

The action against Fox is part of an ongoing series of oversight, disciplinary and enforcement actions by CMS against Medicare Advantage and other federal health care program participants. These programs and CMS’ oversight and enforcement of federal programs are drawing increasing Congressional scrutiny in connection with Congressional health care reform efforts. Amid this heightened scrutiny, Medicare Part D and Medicare Advantage Plans; health care providers, administrative services providers and others contracting with these plans and others involved with this programs should take appropriate action to maintain compliance, tighten their contracts with and oversight of actions of partners and vendors performing critical functions; review complaint reporting, investigation and response processes and procedures; and strengthen other practices to minimize exposures to audit or other enforcement actions.

For Assistance With Medicare Managed Care or Other Matters

If your organization needs advice or assistance about Medicare Part D or other Medicare Advantage contracting or other requirements or about other health plan or health care matters, consider contacting the author of this article, Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail here.

Past Chair of the ABA Health Law Section Managed Care & Insurance Section, Chair of the American Bar Association RPTE Employee Benefits & Compensation Committee and an ABA Joint Committee on Employee Benefits Council member, Ms. Stamer has more than 22 years experience advising health plans, health care providers, and other health industry and insurance clients. Her experience includes specific experience assisting Medicare, Medicaid and other health plan sponsors, administrators, or administrative services providers about contracting, compliance, coverage and other matters. A popular lecturer and widely published author on health industry matters, Ms. Stamer also conducts compliance and other training on Medicare Advantage and other contract and compliance matters, as well as a broad range of other health industry related concerns. Ms. Stamer also publishes and speaks extensively on health and managed care industry quality, regulatory, reimbursement, and other operations, risk management and public policy concerns. Her insights on health industry matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications. For additional information about Ms. Stamer, her experience, involvements, programs or publications, see here.

Other Recent Developments & Resources

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You can review other recent health plan, health care and internal controls resources and additional information about the health industry and other experience of Ms. Stamer here. 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 at here; e-mailing this information to cstamer@cttlegal.com; or registering to participate in the distribution of these and other Solutions Law Press updates here. For important information concerning this communication click here.

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Leave a Comment » | Consumer Driven Health Care, Doctor, false claims act, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health Plan, Health Plans, Medicaid, Medicare, Medicare Advantage, Medicare Prescription Drug Program, OIG, Physician, Prescription Drugs | Tagged: Doctor, Health Care, Health Care Fraud, Health Care Provider, health care quality, Health Care Reform, Health Care Reimbursement, Health Insurance, Health Plans, Health Policy, HHS, Hospital, Medicare, Medicare Advantage, Medicare Part D, Physician, Physicians, Prescription Drugs, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

AHRO Invites Comments On Project To Develop & Test Hospital Toolkit Intended To Guide Hospitals In Using AHRQ Quality Indicators

March 15, 2010

By Cynthia Marcotte Stamer

April 12, 2010 is the deadline for interested person to comment on the request by the Agency for Healthcare Research and Quality (AHRQ) for approval of its proposed “Development and Evaluation of AIIRQ’s Quality Indicators Improvement Toolkit” information collection project.

AHRO’s mission under 42 U.S.C. 299(b)(1)(F); 299a(a)(1) and (2) is to disseminate information and tools that can support improvement in quality and safety in the U.S. health care community. In furtherance of this mission, AHRQ has developed sets of Quality Indicators (QIs) for use by AHRO and others to document quality and safety conditions at U.S. hospitals. These and other federally established quality standards are a key part of ongoing government efforts to promote quality and cost effectiveness in the U.S. medical system, as well as to tie reimbursement to the satisfaction of these or other government-adopted quality standards.

To encourage broader use and adoption of its QIs by hospitals and others, AHRO now is working on developing and evaluating a toolkit to help hospitals to effectively use AHRQ’s QIs. The proposed AHRO toolkit would use two sets of QIs already developed and evaluated by AHRO:

The Inpatient Quality Indicators (IQIs), which contain measures of volume, mortality, and utilization for common medical conditions and major surgical procedures; and
The Patient Safety Indicators (PSIs), which are a set of measures to screen for potentially preventable adverse events that patients may experience during hospitalization.

The QIs and supportive documentation on how to work with them are posted on AHRQ’s Web site here. Many of the QIs have been endorsed by the National Quality Forum through its consensus review process.

To promote the appropriate use of these tools, AHRO plans to develop and then field test an alpha version of the Quality Indicators Improvement Toolkit with six hospitals. The currently open invitation to comment invites public comment on the proposed information collection efforts to be conducted as part of this phase of the project.

To review the pending request for comment for additional details or instructions on submitting comments, see here.

For Assistance With These Or Other Health Industry Concerns

If your organization needs advice or assistance with commenting on the AHRO proposal or to respond to other health care quality or other health care matters, consider contacting the author of this article, Curran Tomko Tarski LLP Partner Cynthia Marcotte Stamer at (214) 270-2402 or via e-mail here.

Other Recent Developments & Resources

If you found this information of interest, you also may be interested in reviewing some of the following recent Updates available online by clicking on the article title:

For More Information

We hope that this information is useful to you. If you need assistance with auditing or defending these or other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com, Edwin J. Tomko at (214) 270-1405 or another Curran Tomko Tarski LLP Partner of your choice. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other internal controls and risk management matters.

Leave a Comment » | Evidence Based Medicine, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health IT, Health Plan, Health Plans, Hospital, Medicaid, Medical Malpractice, Medicare, Medicare Advantage, Outcomes Data, Physician, Public Policy, Reimbursement | Tagged: AHRO, health care quality, Health Care Reform, Health Carfe, Managed Care, Medicaid, Medicare, Quality Indicators | Permalink
Posted by Cynthia Marcotte Stamer

HHS Delays 2010 HHS Federal Poverty Rate Update To March 1, 2010

January 22, 2010

Rates Often Impact Federal Low Income & Other Charity Programs

By Cynthia Marcotte Stamer

Health care, educational and other charity care and other organizations participating in federal programs that determine eligibility based on the Federal Poverty Rate may continue to rely on 2009 Federal Poverty Rates until at least March 1, 2010. However these federal program participants and other organizations and programs that otherwise rely on Federal Poverty Rates for purposes of making eligibility, sliding scale fees or other determinations will want to watch for the updated guidelines and make appropriate updates as necessary when the new guidelines are released over the next few months.

The U.S. Department of Health & Human Services (HHS) usually issues annual updates to the Federal Poverty Rates in January. However, HHS announced January 22, 2010 that its annual update of Federal Poverty Rates for 2010 will be delayed until at least March 1, 2010. As a result of this announcement, 2009 Federal Poverty Rates will remain in effect for the time being until at least March 1, 2010.

Health care organizations and a wide range of other organizations and programs use the Federal Poverty Guidelines to decide program eligibility or fees. Many federal programs use the federal poverty guidelines as one criterion for federal program eligibility. For example, the Medicaid and State Children’s Health Insurance (SCHIP) programs determine eligibility largely on the basis of whether the applicant’s income is below the federal poverty guidelines. Other programs determine financial eligibility based on a percentage or multiplier of the federal poverty guidelines (for example, 125 percent of federal poverty guidelines). In addition, the federal poverty guidelines are used in the immigration context, such as Form I-864 Affidavit of Support.

Under the 2009 Federal Poverty Guidelines continued in force by the HHS announcement, the applicable income amounts under the 2009 Federal Poverty Guideline in the 48 contiguous states and Washington, D.C. are as follows:

2009 Poverty Guidelines for the 48 Contiguous States and the District of Colombia*
Number of Family Members	Poverty Guideline Income
1	$10,830
2	$14,570
3	$18,310
4	$22,050
5	$25,790
6	$29,530
7	$33,270
8	$37,010
8+	Add $3,740 for each additional person.
* Alaska and Hawaii have slightly higher poverty guidelines.

In addition to determining eligibility for purposes of many federal programs, many health care and social services organizations, especially non-profit organizations, utilize a sliding fee scale or fee waiver based on the federal poverty guidelines. In addition, many health care organizations base their charitable care policies on the federal poverty guidelines. For programs where the use of federal poverty guidelines is optional, organizations may want to evaluate whether business or operational needs or other considerations merit any adjustment or use of alternative standards at this time.

While use of the federal poverty guidelines is not mandated by law except by federally funded programs, the Joint Commission as part of its accreditation and survey process may ask whether the organization has utilized the most recent update to the federal poverty guidelines in its sliding scale or fee waiver policies. Therefore, hospitals and other organizations subject to Joint Commission or other accreditation relying on the Federal Poverty Guidelines should review their charity care or fee waiver policies and monitor for planned updates.

Solutions Law Press author and Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health care practitioners and other businesses and business leaders to establish, administer, investigate and defend health care fraud and other compliance and internal control policies and practices to reduce risk under federal and state health care and other laws. You can get more information about the CTT Health Care Practice and Ms. Stamer’s health industry experience here.

If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer, CTT Health Care Practice Group Chair, at cstamer@cttlegal.com, 214.270.2402or another Curran Tomko Tarski LLP attorney of your choice.

Other Helpful Resources & Other Information

We hope that this information is useful to you. If you found these updates of interest, you also be interested in other updates on HEAT activities such as the following:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please register to receive this Solutions Law Press Health Care Update here and be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. You can access other recent updates and other informative publications and resources provided by Curran Tomko Tarski LLP attorneys and get information about its attorneys’ experience, briefings, speeches and other credentials here.

For important information concerning this communication click here. If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject here.

Leave a Comment » | Centers For Disease Control, Childrens Health Insurance Program, Corporate Compliance, Doctor, Grants, Health Care, Health Care Finance, Health Care Provider, Health Plan, Hospital, Indian Health, Medicaid, Medicare Advantage, Mental Heatlh, Nonprofits, Reimbursement, Rural Health Care, Tax, Tax-Exemption | Tagged: 501(c)(3), Charity, Health Care, HHS, Joint Commission, Medicaid, Poverty Guidelines, SCHIP | Permalink
Posted by Cynthia Marcotte Stamer

OIG Special Fraud Alert Targets DME Telemarketing

January 21, 2010

By Cynthia Marcotte Stamer

The Department of Health & Human Services (HHS) Office of Inspector General (OIG) on January 14, 2010 issued a Special Fraud Alert discussing potential violations of the anti-kickback statute for Federal health care programs durable medical equipment (DME) suppliers making unsolicited telephone calls to Medicare beneficiaries prematurely based only on physicians’ preliminary written or verbal orders or otherwise inappropriately. DME companies and their telemarketing providers should review their current practices in light of the Special Fraud Alert and tighten practices as necessary to comply with its guidance.

The January 14, 2010 Special Fraud Alert focuses on the continuing efforts by some DME companies to circumvent the telemarketing prohibits on Section 1834(a)(17) by using independent marketing firms to make unsolicited telephone calls to Medicare beneficiaries to telemarket DME based on preliminary written or oral DME orders of physicians. DME companies and their telemarketing providers should review their current practices in light of the Special Fraud Alert and tighten practices as necessary to comply with its guidance. Read more here

Over the past year, HHS, the Department of Justice and other federal officials have significantly turned up the heat on health care fraud investigation and enforcement, During December, 2010 alone, the Department of Justice reported more than 15 criminal fraud enforcement actions. See Federal HEAT & Other Federal Health Care Fraud Efforts Score More Than 15 Successes As OIG Claims $20.97 Billion Saved From Enforcement Activities In December. These and other reports document the rising prosecution and enforcement risks that health care providers face for failing under federal health care fraud laws. In light of the growing enforcement and emphasis of federal prosecutors and regulations on the detection and prosecution of organizations and individuals participating in billing or other activities that violate federal health care fraud laws, health care organizations, their officers, directors, employees, consultants and other business partners should tighten practices and step up oversight to minimize the likelihood that they or their organizations will engage in activities that federal regulators view as federal health care fraud. Health care providers need to strengthen existing practices to withstand federal scrutiny, as well as to identify appropriate counsel, established plans and procedures and implement other arrangements for responding in the event the Department of Justice, HHS or other federal regulators audit or take other action regarding their practices or billings.

For More Information

We hope that this information is useful to you. If you found these updates of interest, you also be interested in other updates on HEAT activities such as the following:

If you need assistance with these or other health care fraud, compliance, reimbursement, risk management, workforce and other health care concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other reimbursement, operations, internal controls and risk management matters. You can review other recent health care and related resources and additional information about the health industry and other experience of Ms. Stamer here.

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 at here or e-mailing this information here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | Corporate Compliance, Durable Medical Equipment, false claims act, Federal Sentencing Guidelines, Health Care, Health Care Fraud, Hospital, Medicaid, Medicare, Medicare Advantage, OIG, Physician, Reimbursement, Telemarketing, Telemedicine | Tagged: Durable Medical Equipment, False Claims, Health Care Fraud, Medicaid, Medicare, OIG, Reimbursement, Telemarketing | Permalink
Posted by Cynthia Marcotte Stamer

Federal HEAT & Other Federal Health Care Fraud Efforts Score More Than 15 Successes As OIG Claims $20.97 Billion Saved From Enforcement Activities In December

December 30, 2009

As the interagency Medicare Fraud Strike Force targeting Medicare Fraud scored another series of more than 15 successful criminal enforcement actions across the national during December, 2009, the Department of Health & Human Services (HHS) Office of Inspector General (OIG) credited the Medicare Fraud Strike Force and other stepped up oversight and enforcement activities as helping it achieve $20.97 Billion in Medicare and other federal health care program savings during Fiscal Year 2009 in its Semiannual Report to Congress.

The Detroit convictions were among three of more than 15 other criminal enforcement successes reported by the Department of Justice during December. These and other reports document the rising prosecution and enforcement risks that health care providers face for failing to tailor their billing and other practices to comply with federal health care fraud laws. In light of the growing enforcement and emphasis of federal prosecutors and regulations on the detection and prosecution of organizations and individuals participating in billing or other activities that violate federal health care fraud laws, health care organizations, their officers, directors, employees, consultants and other business partners should tighten practices and step up oversight to minimize the likelihood that they or their organizations will engage in activities that federal regulators view as federal health care fraud.

December 13 Detroit Criminal Convictions

The U.S. Department of Justice Criminal Division (Justice Department), Federal Bureau of Investigation (FBI) and Inspector General for the U.S. Department of Health and Human Services (HHS) jointly announced Friday (December 11, 2009) that Baskaran Thangarasan, Sandeep Aggarwal and Wayne Smith had plead guilty for their roles in connection with several Detroit-area health care fraud scheme.

On December 9, 2009, Thangarasan plead guilty to one count of conspiracy to commit health care fraud and Aggarwal plead guilty to one count of conspiracy to launder money. On December 11, 2009, Smith plead guilty to one count of conspiracy to commit health care fraud.

Thangarasan Guilty Plea To Conspiracy To Commit Health Care Fraud

On December 9, 2009, Thangarasan plead guilty to one count of conspiracy to commit health care fraud. And Aggarwal plead guilty to one count of conspiracy to launder money. He faces a maximum sentence of 10 years in prison and a $250,000 fine at sentencing.

According to information contained in plea documents, Thangarasan, a licensed physical therapist, admitted that he began working in approximately September 2003 as a contract therapist for a co-conspirator. This co-conspirator owned and controlled several companies operating in the Detroit area that purported to provide physical and occupational therapy services to Medicare beneficiaries. Thangarasan admitted that he, the co-conspirator and others created fictitious therapy files appearing to document physical therapy services provided to Medicare beneficiaries, when in fact no such services had been provided. According to court documents, the fictitious services reflected in the files were billed to Medicare through sham Medicare providers controlled by Thangarasan’s co-conspirators.

Thangarasan admitted that his role in creating the fictitious therapy files was to sign documents and progress notes indicating he had provided physical therapy services to particular Medicare beneficiaries, when in fact he had not. Thangarasan was paid approximately $50 by co-conspirators per file that he falsified in this manner. Thangarasan also admitted that in the course of the scheme charged in the indictment, he signed approximately 1,011 fictitious physical therapy files, falsely indicating he had provided physical therapy services to Medicare beneficiaries. Thangarasan admitted he knew that the files he helped falsify were used to justify fraudulent billings to Medicare.

In addition, Thangarasan admitted that between approximately September 2003 and May 2006, his co-conspirators submitted claims to the Medicare program totaling approximately $5,055,000 for files that were falsified by Thangarasan. Medicare actually paid approximately $2,325,000 on those claims. Thangarasan admitted that throughout the conspiracy, he was fully aware that Medicare was being billed for occupational therapy services he had falsely indicated he had performed.

Aggarwal Guilty Plea to Money Laundering

Aggarwal faces a maximum sentence of 20 years in prison and a $500,000 fine after admitting in the same case to assisting co-conspirator Suresh Chand in laundering the proceeds of Chand’s Medicare fraud scheme. Chand, who pleaded guilty in September 2009 to conspiracy to commit health care fraud and conspiracy to launder money, admitted to conspiring to submit approximately $18 million in fraudulent physical and occupational therapy claims to the Medicare program. Aggarwal, who admitted working at Chand’s office, acknowledged that his role in the scheme was to set up sham entities at Chand’s direction, with the purpose of using those entities to distribute the proceeds of the fraud to the various co-conspirators. According to plea documents, one such entity was called Global Health Care Management Services. Aggarwal admitted that Global Health Care Management Services, which he helped create, provided no health or management services of any type, but existed solely as a mechanism to conceal the location of fraudulently obtained Medicare proceeds. Aggarwal admitted in his plea that he and Chand laundered approximately $393,000 through this sham entity.

Smith Guilty Plea To Conspiracy To Commit Health Care Fraud

At sentencing, Smith face a maximum sentence of 10 years in prison and a $250,000 fine for his participation in a scheme to falsely bill Medicare. His indictment charged that he transported and paid Medicare beneficiaries to attend Sacred Hope Center, a Southfield, Mich.-infusion clinic. According to the indictment, the Medicare beneficiaries he paid and transported were paid to sign paperwork indicating that they had received infusions and injections of specialty medications that they did not in fact receive.

According to the indictment, Sacred Hope Center routinely billed the Medicare program for services that were medically unnecessary and/or never provided. The primary owners and operators of Sacred Hope Center have pleaded guilty and admitted purchasing only a small fraction of the medications that the clinic billed the Medicare program for providing. These co-conspirators have also stated that patients were prescribed medications at the clinic based not on medical need, but instead based on which medications were likely to generate Medicare reimbursements.

Other Criminal Enforcement Actions During December

The Detroit convictions are three of nearly 20 successful criminal enforcement activities that DOJ announced during December, 2009. During the same month, DOJ also announced:

On December 20, 2009, sentencing of an Audiologist to six months in prison for Medicare Fraud in California here
On December 17, 2009 , the guilty plea and sentencing of a Houston physician for operating an illegal pill mill here
On December 16, 2009, the sentencing in Michigan of the owner of health care agency to 18 months prison in Medicare kickback scheme here
On December 15, 2009, the sentencing of a Lexington. South Carolina doctor to perform community service in a health care fraud case here
On December 15, 2009, the guilty plea of a Plymouth, Minnesota man to defrauding Medicaid out of $74,000 here
On December 14, 2009, the sentencing of a Miami, Georgia man to more than a decade in Federal prison for million dollar Medicaid fraud here
On December 11, 2009, the charging of a durable medical equipment company and six other defendants in Pennsylvania in a Medicare Fraud And Kickback Scheme here
On December 11, 2009, the guilty plea of an Aulander, North Carolina woman to $650,000 Health Care Fraud here
On December 7, 2009, the guilty plea of a corporation various health care fraud schemes here
On December 6, 2009, the guilty plea of a Dallas, Texas durable medical equipment business owner to aggravated id theft in a Medicare Fraud scheme here
On December 3, 2009, the arrest of the owner of a Florida home health care provider and his alleged accomplice for a scheme to bribe a government contractor here
On December 3, 2009, the conviction of two defendants for Health Care Fraud in Idaho here
On December 2, 2009, the entry of an order requiring a Sioux City, Iowa hospital to pay $400,000 to resolve false claims allegations here
On December 1, 2009, the admission by a Maryland man to health care fraud on a hospital in the District of Columbia here
On December 1, 2009, the arrest of a Miami, Florida man for obstructing a Health Care Fraud Investigation here
On December 1, 2009, the $125,000 fine of a Michigan chiropractor for Falsifying Records here

HEAT Operations Continued & Expanded

The Detroit and many of these other criminal successes resulted from joint investigations by the FBI and the OIG as part of the Medicare Fraud Strike Force as part of various interagency Medicare Fraud “Strike Forces” operating in several regions of the U.S. as part of the continuing Health Care Fraud Prevention and Enforcement Action Team (HEAT) operations of the FBI, HHS and the Justice Department which DOJ credits with producing more than 250 criminal convictions since their inception, Based on initial successes of Strike Force operations in Miami (Phase One) and Los Angeles (Phase Two), the Justice Department and HHS on May 20, 2009 expanded the scope of these operations to include Detroit and Houston Strike Force teams. Recently, DOJ and HHS announced the expansion of its HEAT operations to include Strike Force teams also targeting health care fraud in Brooklyn, New York; Tampa, Florida and Baton Rouge, Louisiana.

The heightened emphasis on enforcement of federal health care fraud laws reflected in the HEAT program the enactment of recent amendments to the False Claims Act, 31 U.S.C. § 3729 (FCA) under the “Fraud Enforcement and Recovery Act of 2009”(FERA). The FERA amendments increase the likelihood both that whistleblowers will turn in health care providers and other individuals and organizations that file false claims in violation of the FCA and the liability that violators may incur for that misconduct.

The FERA amendments and the HEAT Team and Strike Force activities are part of a broader emphasis in the enforcement of federal health care fraud laws by both the Administration and Congress. President Obama’s proposed Fiscal Year 2010 budget seeks to further increase funding for fraud prevention and enforcement by investing $311 million — a 50 percent increase from 2009 funding — to strengthen program integrity activities within the Medicare and Medicaid programs. The Obama Administration anticipates that all combined, the anti-fraud efforts in the President’s budget could save $2.7 billion over five years by improving oversight and stopping fraud in the Medicare and Medicaid programs, including the Medicare Advantage and Medicare prescription drug programs. Many state agencies also are stepping up their health care fraud investigations and enforcement.

Health Care Providers Must Step Up Compliance & Risk Management

In light of this new emphasis upon health care fraud detection and enforcement, health care providers now more than ever need to prepare to demonstrate the appropriateness and defensibility of their health care billing and other compliance efforts.

Solutions Law Press author and Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health care practitioners and other businesses and business leaders to establish, administer, investigate and defend health care fraud and other compliance and internal control policies and practices to reduce risk under federal and state health care and other laws. You can get more information about the CTT Health Care Practice and more specifics about Ms. Stamer’s health industry experience here on the CTT Website.

If you need assistance with these or other compliance concerns, wish to inquire about arranging for compliance audit or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer, CTT Health Care Practice Group Chair, at cstamer@cttlegal.com, 214.270.2402, CTT White Collar Defense Litigation Practice Chair Edwin J. Tomko at etomko@cttlegal.com, or 214.270.1405 or another Curran Tomko Tarski LLP attorney of your choice..

Other Helpful Resources & Other Information

We hope that this information is useful to you. If you found these updates of interest, you also be interested in other updates on HEAT activities such as the following:

Other recent updates that also may be of interested published on our electronic Solutions Law Press Health Care Update publication include:

For important information concerning this communication click here. If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject here.

Leave a Comment » | Anti-KickBack, Corporate Compliance, false claims act, Federal Sentencing Guidelines, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Hospital, Inpatient Rehabilitation Facility, Medicaid, Medicare, Money Laundering, OIG, Physician, Reimbursement, Stark | Tagged: Corporate Compliance, Doctor, false claims act, Federal Sentencing Guidelines, Fraud, Health Care, Health Care Fraud, Health Care Provider, Health Care Reimbursement, HHS, Hospital, Identity Theft, Medicare, Medicare Part B, Physician, Physicians, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

Chisholm Trail Chapter Association of Certified Fraud Specialists December 11, 2009 Chapter Meeting & Luncheon Invite

November 16, 2009

The Chisholm Trail Chapter of the Association of Certified Fraud specialists invites members and other interested persons to attend its December 11, 2009 Chapter Meeting on December 11, 2009 beginning at 10:30 a.m. in the DCIS Conference Room located at 2201 N. Collins, Arlington, TX.

Interested persons should RSVP to and arrange for the required registration fee for the pre-paid luncheon (barbecue w/fixings) in the amount of $12.00 per person to be made payable to and received by the following no later than December 4, 2009:

Make checks payable to: Carlos Ontiveros, POB 227238, Dallas, Tx 75222-7238

To RSVP or for additional information, please e-mail here.

We hope that this information is useful to you. If you need assistance with these or other health care public policy, regulatory, compliance, risk management, workforce and other staffing, transactional or operational concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270‑2402, cstamer@cttlegal.com. Ms. Stamer has extensive experience advising clients and writes and speaks extensively on these and other health industry and other reimbursement, operations, internal controls and risk management matters. You can review other recent health care and related resources and additional information about the health industry and other experience of Ms. Stamer here.

Leave a Comment » | Anti-KickBack, Health Care, Health Care Fraud, Medicaid, Medicare, Reimbursement | Tagged: Health Care, Health Care Fraud, Health Care Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

Renal Dialysis Faculties Encouraged to Review Current Protocols for Administering Erthropoiesis-Stimulating Agents

November 6, 2009

Renal Dialysis Facilities are encouraged to review and consider the advisability for further tightening of their current practices in light of the Renal Dialysis Facilities’ Dosage Protocols for Administering Erthropoiesis-Stimulating Agents, (OEI-03-09-00010), posted by the OIG this week.

According to the report, OIG conducted the report in response to a request from Chairman Fortney Pete Stark of the Subcommittee on Health, Committee on Ways and Means, U.S. House of Representatives in response to reported concerns by some members of Congress that dialysis facilities’ protocols for administering ESAs may not be consistent with the current boxed warning for these drugs.

OIG found that 93 percent of Medicare-certified dialysis facilities had protocols in place for administering erythropoiesis-stimulating agents (ESA), but only 56 percent of the facilities’ protocols explicitly state a target hemoglobin range. OIG could not determine whether the remaining 44 percent of protocols were consistent with the boxed warning and Medicare’s benefit policy because they do not specify a target hemoglobin range. Of the protocols that state a target hemoglobin range, 94 percent are consistent with the boxed warning on FDA-approved labeling and the Medicare benefit policy for ESAs.

While noting they are not required to do so, OIG commented that dialysis facilities may develop their own protocols for administering ESAs to patients with chronic kidney failure. The protocols may define target hemoglobin levels and dosage instructions for administering ESAs. According to the boxed warning on ESAs’ labels, maintaining higher rather than lower hemoglobin levels in a patient with chronic kidney failure can adversely affect the patient’s health and increase the risk of death. Specifically, the boxed warning states that providers should administer ESAs “to achieve and maintain hemoglobin levels within the range of 10 to 12 g/dL.” The Medicare benefit policy for ESAs reflects the target hemoglobin range specified in the boxed warning. A separate Medicare policy for monitoring ESA payments states that CMS will reduce reported dosages upon which ESA claims are paid when patients’ hemoglobin levels exceed 13g/dL.

OIG reported its review of protocols to determine whether they are consistent with selected guidelines on ESAs’ labels revealed that some protocols contain information that differs from labeling guidelines regarding starting doses, dose adjustments, and withholding ESA doses. OIG also found that all of the protocols that include a target hemoglobin range or level at which to increase ESA doses conform with CMS’s monitoring policy.

OIG concluded that although its review does not address the amount of ESAs that providers actually administer to patients at their dialysis facilities, it does demonstrate that just over half of facilities’ protocols for administering ESAs are consistent with the boxed warning and Medicare’s benefit policy for ESAs. However, since almost half of the dialysis facilities either did not have protocols or did not specify a target hemoglobin range in their protocols, OIG reported it could not determine whether these facilities’ policies target the hemoglobin range outlined in the boxed warning that FDA requires on ESA labels.

For More Information

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 at here or e-mailing this information here, by subscribing to receive these updates in blog form here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | Evidence Based Medicine, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Hospital, Medicaid, Medicare, OIG, Reimbursement, Stark | Tagged: Dialysis, Health Care, HHS, Kidney, OCR, Reimbursement | Permalink
Posted by Cynthia Marcotte Stamer

Senate Finance Committee Releases Statutory Language of America’s Healthy Future Act To Present To Full Senate

October 22, 2009

Americans finally have a chance to read the actual statutory language of the painfully negotiated package of proposed health care reforms that the Senate Finance Committee proposes for adoption. The Senate Finance Committee leadership finally finished drafting has posted the 1506 page long text of the proposed statutory language of the health care reform provisions of the “America’s Healthy Future Act” on its website here.

When the Senate Finance Committee vote passing the America’s Health Future Act, members of the Senate Finance Committee had not yet had the opportunity to review the actual statutory language to be proposed to implement the package of heatlh care reforms painfully hashed out in their committee. As the actual statutory language had not been completed at the time a majority of the Democrats and one Republican Senator serving on the Senate Finance Committee voted to send the legislation to the the full Senate, the vote actually was taken based on a narative description of the intended reforms set forth in a revised draft of the “Chairman’s Mark” of the legislation. Since that time Senate Finance Committee Chairman Max Baucus and other key Democrat Senators on the Senate Finance Committee have worked behind closed doors to prepare the actual statutory language to be presented to the full Senate.

As proposed, the America’s Healthy Future Act would require sweeping changes to the U.S. health care systems that if adopted will radically impact the roles and responsibilities of every patient, health care provider, health care payor, employer and other American. Because of the potential implications on the way health care is financed, delivered and administered and the projections that the legislation will cost approximately $1 Trillion, all parties are urged to carefully review the complex and lengthy legislation to gain an understanding of the legislation and to act quickly to make any concerns known to elected leaders in Congress.

For More Information

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 at here or e-mailing this information here and/or by participating in the SLP Health Care Risk Management & Operations Group on LinkedIn. To unsubscribe, e-mail here.

Leave a Comment » | America's Healthy Futures Act, Anti-KickBack, ASC, Childrens Health Insurance Program, Consumer Driven Health Care, Doctor, Electronic Medical Records, Employer, Health Care, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, Health Care Reform, Health Insurance Exchange, Health IT, Health Plan, Health Plans, Hospital, Indian Health, Inpatient Rehabilitation Facility, Medicaid, Medical Licensure, Medical Malpractice, Medicare, Medicare Advantage, Mental Heatlh, OIG, Physician, Prescription Drugs, Reimbursement, Rural Health Care | Permalink
Posted by Cynthia Marcotte Stamer

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Partnership Expands Use & Reach of New Affordable Care Act & Other Health Care Fraud Detection & Enforcement Tools & Collaboration

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Health Care Providers Should Strengthen HIPAA Compliance & Defenses As Risks Rise

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December 13 Detroit Criminal Convictions

Thangarasan Guilty Plea To Conspiracy To Commit Health Care Fraud

Aggarwal Guilty Plea to Money Laundering

Smith Guilty Plea To Conspiracy To Commit Health Care Fraud

Other Criminal Enforcement Actions During December

HEAT Operations Continued & Expanded

Health Care Providers Must Step Up Compliance & Risk Management

Other Helpful Resources & Other Information

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