Saturday, November 22, 2008

Qualifications for a Job in anti-medicare medicaid fraud

Post Date 11/12/2008

Employer WellPoint, Inc

Job Description

TrustSolutions is a wholly owned subsidiary of Government Health Services, LLC, and is part of the WellPoint family of companies. TrustSolutions holds a Medicare Program Safeguard contract with the Centers for Medicare & Medicaid Services to help reduce fraud and abuse in the Medicare Program. Headquartered in Milwaukee, Wisconsin, TrustSolutions also has offices in California, Illinois, Michigan, Virginia, Indiana, Florida and Texas.

Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

Healthcare Fraud Program Director
This position is contingent upon contract award, and can be filled in any of these locations: PA, NY, MD, DC, DE, ME, MA, NJ, CT, RI, NH, VT

Responsible for the development and ongoing management of Medicare and Medicaid Program Integrity anti-fraud programs that are multi-state, multi-function and multi-year in scope. Provides leadership to program managers, project managers and sub-contractors. Typically reports to an executive or senior manager. Program directors typically manage programs, their associated budgets and compliance with contractual requirements that require managing activities and resources of multiple departments or business areas of the organization. Program directors typically support business strategies through an integrated portfolio of programs, projects and initiatives. Essential duties include, but are not limited to: coordinates and manages the development, approval, implementation and compliance of on-going programs; establishes program governance when needed to assure response to issue escalation; develops program budget; ensures program meets its stated objectives; provides subject matter expertise in response to day to day business issues; researches applicable subject matter practices and remains aware of industry trends; manages relationships and partners with corporate and regional business areas; coordinates training related to program; develops program success measures and performs periodic assessments of program success; and performs other duties as assigned.


BA/BS degree and 14 years of experience in related field or an equivalent combination of education and experience or 10 years related experience and a MA degree required with at least 3 years as a manager responsible for managing complex systems and work flows or large contracts for private insurance companies, federal agencies or state agencies related to the detection and prevention of healthcare fraud.
Understanding of complex business processes related to federal contracting required.
Project management experience preferred.
2+ years experience with Medi Medi data
2+ years experience with Medicare Program Integrity Work
2+ years experience with Medicare, Medicaid, or Medi-Medi data analysis
3+ years experience with Medicare claims, including types A, B, C, D, DMEOS, and Regional Home Health
Demonstrated leadership skills and proven planning and organization skills to ensure development and maintenance of relationships across organization is required.

Wednesday, November 12, 2008

Healthcare fraud probes given more resources

Posted: November 11, 2008 - 3:00 pm EDT

The Justice Department’s inspector general found that U.S. attorneys directed more attorney hours toward healthcare fraud, firearms and organized crime than their offices were allocated, while extra positions Congress funded for counterterrorism went unfilled.Offices in large cities were most likely to dedicate more attorney hours to healthcare fraud, according to an audit report examining the resource management of the Justice Department’s 94 U.S. attorneys’ offices. The offices in Baltimore; Dallas; Detroit; the Eastern District of New York, which includes Brooklyn and Queens; Houston; Los Angeles; Miami; and Washington each dedicated two to five times their allocated number of full-time employees for healthcare.
Beginning in fiscal 2006, Congress allocated an additional 43 full-time-equivalent positions to counterterrorism but the inspector general found roughly the same number of attorneys with that focus through 2007 as in 2003. The Executive Office for U.S. Attorneys told auditors that the numbers were partially a result of the timing of the appropriations, inaccurate time reporting by attorneys and fewer terrorism matters referred to the offices than in previous years. Director Kenneth Melson, in a response to the inspector general, notes that U.S. attorneys are appointed by the president and are “afforded significant discretion to manage his or her office according to locally perceived priorities and needs.”

The report, however, finds fault with the data relied on to make decisions and with individual attorney evaluations that are performed infrequently because of budget constraints. -- by Gregg Blesch

Justice Department Announces 2008 Fraud & "Qui Tam" False Claims Act Recoveries...

Posted On: November 11, 2008 by Finch McCranie, LLP

Justice Department Announces 2008 Fraud & "Qui Tam" False Claims Act Recoveries, with Medicare, Medicaid, and Other Health Care Fraud Alone Topping $1 Billion in Recoveries of Taxpayer Funds
Will Wall Street Bailout Produce the Next Round of Whistleblowers Reporting Fraud?

The U.S. Department of Justice this week announced its FY 2008 recoveries in fraud and False Claims Act cases, with more than $1 billion in health care fraud recoveries alone, and a total of more than $1.3 billion. (As explained below, we believe the $1.3 billion figure is low and understates the actual fraud recoveries this year.)

Cases brought by "relators" or whistleblowers under the nation's primary whistleblower statute, the False Claims Act, accounted for 78% of the money recovered. Since the False Claims Act took its current form in 1986, this law has recovered more than $21 billion of taxpayer funds from those who defraud the government.

As health care costs have grown as a percentage of the federal budget, so have recoveries for health care fraud. Recoveries of federal dollars were made because of fraud not only in Medicare and Medicaid, but also other federal programs such as Tricare and the Federal Employees Health Benefits Program.

The largest recoveries were from pharmaceutical companies--Cephalon Inc., Merck & Co. and CVS Caremark Corp. paid more than $640 million. Pharmaceutical fraud cases also repaid $430 million to state Medicaid programs.

DOJ also cited recoveries in cases of fraud affecting defense procurement contracts, disaster assistance loans and agricultural subsidies.

The actual recoveries were greater if you compare DOJ's announcements of its settlements, as well as include dollars recovered under the various State False Claims Acts. (We have written extensively about why states are enacting their own State False Claims Acts to mirror the federal False Claims Act, given the federal law's successes.)

With whistleblowers reporting fraud infecting in the Wall Street bailout funds (because no federal program is immune), it will be interesting to see how these billions of federal dollars show up in future statistics of fraud recoveries.

We have reprinted below DOJ's "fact sheet" about its FY 2008 significant recoveries. We congratulate Justice on another very successful year in fighting fraud and false claims.


Among the Department’s most significant settlements and judgments in fiscal year 2008 were:
• $361.5 million from Merck & Company to resolve allegations that the pharmaceutical manufacturer knowingly failed to pay proper rebates to Medicaid and other government health care programs, and paid kickbacks to health care providers to induce them to prescribe the company’s products. The settlement resulted from two lawsuits brought under the qui tam provisions of the False Claims Act.
In the first, which accounted for $221.9 million of the $361.5 settlement, a former Merck employee alleged that the company violated the Medicaid Rebate Statute by providing deep discounts to hospitals that used its drugs Zocor and Vioxx in place of competitors’ brands, without reporting those discounts and other cost information to reflect its "best price," as required by the statute to ensure that Medicaid obtains the benefit of the same price concessions other purchasers enjoy. This suit also alleged that Merck paid kickbacks to physicians, disguised as fees for training, consultation, and market research, to induce them to prescribe its drugs, also contrary to law. The United States paid the relator $46.6 million as his share of the settlement under the False Claims Act’s qui tam provisions. In addition to the federal recovery, Merck paid $162 million to state Medicaid programs.

In the second lawsuit, which accounted for the remaining $139.6 million of the settlement, a physician alleged that Merck provided deep discounts to hospitals to induce them to administer its antacid, Pepcid, as a means to boost sales through continued use after the patient’s discharge. The suit went on to allege, similar to the first suit, that Merck knowingly failed to report these discounts as required by the Medicaid Rebate Statute, which resulted in illegal and inflated claims to federal and state Medicaid programs. In addition to paying the United States $139.5 million in federal claims, Merck paid $114 million to settle state Medicaid claims. The relator received $24 million as his federal share of the settlement and an additional sum for the state recoveries. Merck also entered into a Corporate Integrity Agreement with the Inspector General of the Department of Health and Human Services (HHS) to ensure compliance with federal health insurance programs in the future.

For the original press release, see:

• $258 million from Cephalon Inc. to resolve claims that the company marketed three drugs for uses not approved by the Food and Drug Administration (FDA). By promoting the drugs for so-called "off label" uses, Cephalon caused providers to charge federal health insurance programs such as Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits Program for unapproved uses of the drugs not covered by the programs. The settlement resolved four lawsuits, three of which were brought by former Cephalon sales representatives under the qui tam provisions of the False Claims Act. Consistent with those provisions, the relators who filed the suits will share $46.7 million as their part of the settlement. In addition to the $258 million recovered for federal programs, the United States recovered $116 million for the Medicaid programs in 14 states and the District of Columbia. Cephalon also pleaded guilty to related criminal charges, paid $50 million in fines and forfeitures and entered into a five-year Corporate Integrity Agreement with the Inspector General of HHS to ensure strict compliance in the future.
For the original press release, see:

• $225 million from Amerigroup Corporation to settle both federal and state allegations that Amerigroup, together with its Illinois subsidiary, systematically avoided enrolling pregnant women and other high-cost patients in the company’s managed care program in Illinois. The program was funded by Medicaid, which required open enrollment to all eligible beneficiaries. By excluding pregnant women and other high-cost patients, Amerigroup increased its profits in conflict with the law. The United States and Illinois jointly brought suit under the federal False Claims Act and the Illinois Whistleblower Reward and Protection Act. In October 2006, following a lengthy trial, the court entered judgment for $334 million. Amerigroup appealed and the parties entered negotiations leading to settlement. The relator received $56.25 million as his share of the federal and state recoveries. In conjunction with the settlement, Amerigroup entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $75 million to settle claims that Kyphon Inc., now Medtronic Spine LLC, violated the False Claims Act by knowingly causing the submission of false claims to Medicare for its kyphoplasty procedure–a minimally-invasive surgery used to treat compression fractures of the spine. The settlement resolved a lawsuit filed by two former Kyphon employees under the qui tam provisions of the False Claims Act. The suit alleged that Kyphon engaged in a seven-year marketing scheme that resulted in certain hospitals billing Medicare for kyphoplasties performed on an inpatient basis rather than for less costly and clinically appropriate outpatient kyphoplasty treatment. This conduct resulted in the Medicare program paying more for inpatient kyphoplasty procedures. The relators received a total of $14.9 million as their share of the settlement. In conjunction with the settlement, Kypon entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $74 million from Staten Island University Hospital (SIUH) to resolve two False Claims Act qui tam suits and two other matters. In the first action, a physician and former SIUH Director of Chemical Dependency Services, filed suit alleging that SIUH fraudulently billed Medicare and Medicaid for substance abuse and alcohol detoxification services provided to inpatients in unlicensed beds, in violation of state law, between 1994 and 2000. SIUH paid the United States $11.8 million in settlement of this qui tam action, with the relator receiving $2.3 million as his share of the government’s recovery. In related allegations of inflated Medicaid billings asserted under New York State’s false claims statute, SIUH paid New York $14.88 million, with the relator receiving $2.97 million as his share of the state’s recovery.
In the second action, the widow of an SIUH cancer patient filed suit alleging that between 1996 and 2004, SIUH submitted false claims to Medicare and TRICARE using incorrect codes for cancer treatments not covered by the programs. SIUH paid the United States $25 million, including a relator share award of $3.75 million. In the third matter, the United States alleged that SIUH deliberately inflated the number of residents it employed to fraudulently increase Medicare reimbursement between 1996 and 2003. SIUH paid the United States $35.7 million in settlement of this matter. Lastly, SIUH paid the United States $1.47 million to settle allegations that it billed Medicare and Medicaid for treating psychiatric patients in unlicensed beds from 2003-2005. In conjunction with the settlement, SIUH also entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $60 million from Lester E. Cox Medical Centers, a health care system headquartered in Springfield, Mo., to settle claims that it violated the False Claims Act, the Anti-Kickback Statute and the Stark Statute between 1996 and 2005. The United States alleged that Cox entered into illegal financial relationships with referring physicians at a local physician group and engaged in improper billing practices with respect to Medicare. Under the Stark Statute, providers such as Cox are prohibited from billing Medicare for referrals from doctors with whom the providers have a financial relationship, unless that relationship falls within certain exceptions. The United States contended that Cox and the referring physicians ran afoul of the Stark Statute, as well as the Anti-Kickback Statute, which prohibits offering inducements to providers in return for patient referrals. The settlement also resolves claims that Cox included non-reimbursable costs on its Medicare cost reports and improperly billed for dialysis services. In conjunction with the settlement, Cox entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

• $53 million from Pratt & Whitney, a division of United Technologies Corporation, and PCC Airfoils LLC, a subsidiary of Precision Castparts Corporation, to resolve allegations that the companies knowingly submitted false claims for defective turbine blades purchased by the Air Force to retrofit the F100-PW-220 engines found in F-16 and F-15 aircraft. The settlement includes corrective action to replace defective blades and inspection of potentially serviceable blades to ensure their integrity. The case was pursued as part of a National Procurement Fraud Initiative launched in October 2006, to promote the early detection, identification, prevention and prosecution of procurement fraud.

For the original press release, see:

• $26 million from St. Joseph’s Hospital of Atlanta to resolve allegations that the hospital falsely claimed Medicare reimbursement for inpatient admissions that were, in fact, less costly outpatient visits. A registered nurse, formerly employed by the hospital, initiated suit under the False Claims Act’s qui tam provisions. The complaint alleged that the hospital improperly billed for short inpatient admissions, usually of one day or less, when the service should have been billed as an outpatient "observation" or emergency room visit. Medicare reimburses hospitals a higher rate for inpatient admissions than it does for observation care or emergency room visits. The nurse who triggered the investigation received $4.94 million as her share of the recovery. St. Joseph’s entered into a Corporate Integrity Agreement with the Inspector General of HHS in conjunction with the settlement, to ensure future compliance.
For the original press release, see:

• $23.2 million from Bechtel Infrastructure Corp. and PB Americas Inc. to settle allegations of false claims for federal highway funds in connection with the firms’ failure to provide adequate management and quality assurance services during the construction of the Central Artery Tunnel, known as the Big Dig, in Boston. The recovery, part of a $458 million settlement of state and federal claims, resolved parts of a qui tam lawsuit, a related federal investigation and additional claims that Bechtel and PB Americas violated federal and state criminal and civil laws in connection with their services on the Big Dig. In addition to the federal recovery, the companies paid $40 million in state claims and $335 million into a state warranty fund for future repairs to the Big Dig. The private citizen who filed the suit received $54,000 and $96,000 as his share of the federal and state recoveries, respectively.

For the original press release, see:

• $21.1 million from CVS Caremark Corp. to settle claims that from 2000-2006, the company illegally switched patients from the tablet version of the drug Ranitidine (generic Zantac) to a more expensive capsule version for the sole purpose of increasing Medicaid reimbursement. For example, CVS pharmacies in Illinois would charge Medicaid $79.80 for 60 Ranitidine capsules, rather than $17.10 for the tablets prescribed, increasing reimbursement by $62.70 on a single prescription. CVS Caremark is headquartered in Rhode Island and operates more than 6,000 pharmacies nationwide. The settlement resolves qui tam claims under federal and state false claims statutes. In addition to the federal recovery, CVS Caremark paid $15.6 million to 23 states and the District of Columbia. The qui tam plaintiff received $4.3 million as his share of the federal and state settlements. CVS Caremark also entered into a Corporate Integrity Agreement with the Inspector General of HHS to ensure future compliance.

For the original press release, see:

Posted by Finch McCranie, LLP

Saturday, November 1, 2008

Here is one person's definition of Healthcare Fraud...a tip of the GLACIER!

Health Care Fraud Costs Billions
October 10th, 2008 · No Comments

What is Health Care Fraud? Health care fraud occurs when health care professionals make false or misleading statements in order to benefit financially. Health care schemes are diverse and often complex.

Examples include overbilling, billing for services not even provided, double billing for the same procedure, billing for a more expensive procedure than actually performed, or billing separately for items that are less expensive when bundled together (for example a group lab tests). It is also fraudulent to receive a “kickback” for referring a patient to another doctor. Doctors have even been caught selling prescriptions to patients for cash.

Part of the reason health care fraud is so prevalent is because health care is so expensive and is such a massive system. It is not unusual for a carrier to cut a check for over $100,000 to someone it does not even know! Because it is so prevalent, billions of dollars are being drained from the Medicaid and Medicare Industries on fraudulent claims. Scam artists often close up shop and flee before investigators can even attempt to recover the fraudulently obtained funds.

However, the Justice Department has made health care fraud a top priority. Many investigations are the result of complaints from patients and the public at large. Because fraud is conducted for the most part “in secret” these tip-offs from health care consumers are extremely valuable to the FBI and other law enforcement officials. Criminal penalties for health care fraud can be very severe. If you are involved in a health care practice you believe may be considered fraudulent, contact an attorney for more information.