AND WHERE IS THE MONEY? SHOW ME THE MONEY!
Owner of Medical Equipment Company Sentenced to 130 Months in Prison for Health Care Fraud
July 3, 2008
A Miami resident was sentenced to 130 months in prison for his role in schemes to defraud the Medicare program, Acting Assistant Attorney General Matthew Friedrich of the Criminal Division and U.S. Attorney R. Alexander Acosta of the Southern District of Florida has announced.
Gustavo Smith, 43, was sentenced in the U.S. District Court for the Southern District of Florida by Judge Marcia G. Cooke. In addition to the prison sentence, Judge Cooke ordered Smith to serve three years of supervised release following his release from prison, forfeit $287,000 and pay $1,988,969 in restitution to the U.S. Department of Health and Human Services (HHS).
At trial, the jury heard testimony that Smith was the owner of Medstar Services and Orthotics Fitters of Miami, two durable medical equipment (DME) companies that Smith used to submit more than $4.6 million in fraudulent claims to the Medicare program. The items billed by Medstar Services and Orthotics Fitters to the Medicare program were primarily negative pressure pumps and related wound care supplies. Medicare beneficiaries whose names and Medicare numbers Smith used to bill for these items testified at trial that they had never heard of Smith or his companies and that they never needed or received the items being billed to Medicare by Medstar and Orthotics Fitters. Doctors whose provider numbers were used by Smith to bill the Medicare program also testified that they had never heard of Smith or his companies and that they had never prescribed the items being billed by Smith’s companies.
Several of Smith’s associates testified at trial that Smith would open companies in the names of nominee owners, who would be listed as owners in official corporate documents, bank accounts and in official Medicare documents. Once Medicare made payments on the fraudulent claims submitted by Smith’s companies, Smith employed a money launderer to cash the proceeds of the fraud and transfer the cash to Smith. Witnesses also testified that Smith used the Medicare money to buy jewelry, purchase airline tickets for personal travel and make payments on his Mercedes-Benz.
In addition to the Medstar and Orthotics Fitters fraud, witnesses also testified about several other forms of health care fraud in which Smith engaged, including: brokering the purchase and sale of DME companies for the purpose of “burning Medicare,” or submitting more than a million dollars in fraudulent claims within a window of two to three weeks; accepting payments from approximately 180 DME companies in return for agreeing to be listed in official Medicare records as the DME companies’ orthotics fitter, when in reality Smith performed no services for those companies; and owning an interest in two additional medical equipment companies that were committing Medicare fraud.
Following a six-day trial, Smith was convicted on April 23, 2008, of all counts contained in a seventeen count indictment, including conspiracy to defraud the United States, to commit health care fraud, and to cause the submission of false claims; seven counts of health care fraud; seven counts of false claims; one count of conspiracy to launder the proceeds of his crimes; and money laundering. Smith was allowed by the court to remain free on bond after his conviction, with the requirement that he be placed on home confinement with electronic monitoring. On June 14, 2008, Smith violated the terms of his release and fled the country. A warrant has been issued for his arrest.
The case was prosecuted by Trial Attorneys Hank Bond Walther and John K. Neal of the Criminal Division’s Fraud Section in Washington, D.C., with the investigative assistance of the FBI and HHS, Office of Inspector General. The case was brought as part of the Medicare Fraud Strike Force, supervised by the Fraud Section of the Criminal Division and U.S. Attorney Acosta of the Southern District of Florida. From investigations opened during the period of Strike Force operations between March and October of 2007, federal prosecutors have indicted 82 cases with 142 defendants in South Florida. Collectively, these defendants billed the Medicare program for more than $492 million.
Source: DoJ
Net News Publisher for World News
Saturday, August 2, 2008
Whistle-Blower Suits Languish at Justice.....
I wonder why?
Hmmm..........Who do we know IN the WHITE HOUSE that would like to hide this? How much has been paid and to whom?
Instead, we can think about Paris and Brittany!
BOY, are we just a bunch of DUMB AMERICANS
DO not knwo what we have until we lose it and this BUSH has really progressed in that department now hasn't he?
July 3rd, 2008 5:18 pm
A Backlog Of Cases Alleging Fraud
Whistle-Blower Suits Languish at Justice
By Carrie Johnson / Washington Post
More than 900 cases alleging that government contractors and drugmakers have defrauded taxpayers out of billions of dollars are languishing in a backlog that has built up over the past decade because the Justice Department cannot keep pace with the surge in charges brought by whistle-blowers, according to lawyers involved in the disputes.
The issue is drawing renewed interest among lawmakers and nonprofit groups because many of the cases involve the wars in Iraq and Afghanistan, rising health-care payouts, and privatization of government functions -- all of which offer rich new opportunities to swindle taxpayers.
Since 2001, 300 to 400 civil cases have been filed each year by employees charging that their companies defrauded the government. But under the cumbersome process that governs these cases, Justice Department lawyers must review them under seal, and whistle-blowers routinely wait 14 months or longer just to learn whether the department will get involved. The government rejects about three-quarters of the cases it receives, saying that the vast majority have little merit.
Disputes can stay buried for years more while the government investigates the allegations.
"Even if no new cases are filed, it might take 10 years for the Department of Justice to clear its desk. Cases in the backlog represent a lot of money being left on the table," said Patrick Burns, a spokesman for Taxpayers Against Fraud, which advocates for Justice to receive more funding to support cases by whistle-blowers and their attorneys.
Supporters of federal intervention in the cases say the dividends are substantial: In recent years, verdicts and settlements have returned nearly $13 billion to the U.S. government.
At issue in most of the cases is whether companies knowingly sold defective products or overcharged federal agencies for items sold at home or offered to U.S. troops overseas. Under the Civil War-era False Claims Act, workers who file lawsuits alleging such schemes cannot discuss them or even disclose their existence until Justice decides whether to step in.
By its own account, the 75-lawyer unit in Washington that reviews the sensitive lawsuits is overloaded and understaffed. Only about 100 cases a year are investigated by the team, which works out of the commercial litigation branch of Justice's civil division.
Critics argue that the delays are at least partly the result of foot-dragging by Justice and the federal agencies whose position it represents, especially in the touchy area of suppliers that may have overbilled the government for equipment, food and other items used by troops in Iraq and Afghanistan.
Justice lawyers have rejected about 19 cases involving contractor fraud in Iraq and Afghanistan, registering five settlements that resulted in $16 million, officials said. Government officials said this week that they are considering whether to dive into 32 more whistle-blower cases involving Iraq or the Middle East.
"It's just flatly absurd for us to be five years into this war" with so few public cases, said Alan Grayson, a whistle-blower lawyer in Florida who has criticized the Justice effort and who is running for Congress as a Democrat.
In a statement, Justice spokesman Charles Miller said that career lawyers and supervisors base their determinations on merit, not on political sensitivities. "Our decisions to intervene or decline in cases involving Iraq and the Middle East are entirely consistent with our record in [whistle-blower] cases generally," he said.
Help from Justice greatly enhances the chances that a complicated fraud scheme can be unraveled, lawyers say. And department statistics show that cases Justice turns away win paltry, if any, financial recoveries.
Key lawmakers have called on Justice to make false-claims investigations a priority.
"Whistle-blowers are the key to the secrets locked in closets throughout the federal bureaucracy and government contractors," said Sen. Charles E. Grassley (R-Iowa). "These patriotic Americans stick their necks out, against all odds, to help the federal government pursue fraud and save taxpayers tens of billions of dollars that would otherwise be lost."
Last month, Deputy Assistant Attorney General Michael F. Hertz told Congress that "the number and increased complexity of the fraud schemes presented to the department, combined with the volume of cases now under review, certainly present challenges."
Among the largest false-claims cases to date are a $650 million settlement earlier this year by drugmaker Merck in connection with an alleged failure to repay Medicaid rebates; a $515 million deal with Bristol-Myers Squibb to cover illegal drug pricing and marketing; and a $98 million agreement with software maker Oracle over pricing.
If their claims are successful, whistle-blowers can receive a hefty slice of the settlements or verdicts, sometimes as much as 20 percent of the award. A former Merck sales manager collected $68 million earlier this year for his role in exposing an alleged drug-pricing scheme.
Even bigger lawsuits containing potentially explosive allegations are waiting in the wings. The vast majority, more than 500 cases, involve the health-care and pharmaceutical industries and often involve Medicare and Medicaid funds.
Only a few hints of the Iraq and Afghanistan disputes have erupted publicly. One is a suit filed by two former employees of Custer Battles, a defense contracting company in Fairfax. The workers accused the company of inflating expenses on a contract it won to replace the Iraqi currency. After a three-week trial in 2006, a jury found in favor of the plaintiffs and awarded them $10 million. But U.S. District Judge T.S. Ellis III later tossed out the case, ruling that the money at issue, controlled in the early years of the Iraq conflict by the Coalition Provisional Authority, belonged to the Iraqi government, not U.S. taxpayers.
Justice declined the whistle-blowers' request to intervene before the case went to trial, plaintiffs' lawyers said. The government eventually weighed in with a court brief on behalf of the whistle-blowers when the case was appealed.
Frederick M. Morgan Jr., a Cincinnati lawyer who represents whistle-blowers, said that the numbers of lawyers willing to take on cases involving defense contractors has dwindled, in part because of Justice's slow decisions.
One of Morgan's lawsuits, against contractors hired by the Navy to build nuclear submarines and an Ohio company that manufactured submarine valves, took five years to resolve.
Another case, involving the manufacture of the F-22 fighter, was filed in early 1999. It was late 2006 before Justice decided not to intervene. The case is now in active litigation.
"The impact of a 7 1/2 -year delay in the litigation of a case is difficult to quantify but impossible to discount," Morgan said.
Whistle-blower lawyers say other factors can contribute to long delays, including the difficulty in investigating claims in war-torn areas and complications that arise when military officials contend that technology or other products at issue in the lawsuits are classified. In addition, Justice lawyers who handle civil cases often cannot proceed until authorities decide whether a case merits criminal prosecution, the lawyers said.
Even when older cases are pushed into the open, the passage of time can present courtroom challenges.
Last year, a D.C. jury awarded whistle-blower Richard Miller more than $30 million, a figure that now-Chief Judge Royce C. Lamberth tripled to $90 million. But in the dozen years since the suit was filed, witnesses' memories of events had dimmed and the U.S. Agency for International Development had tossed its investigative files.
The judge blasted civil division lawyers for "doing virtually nothing" to follow up for four years after Miller brought forward allegations in 1995 about bid rigging on construction contracts in Egypt. The delays meant "loss of evidence, fading memories, disappearance of documents," he wrote.
Justice spokesman Miller said that the civil case was stalled for years because criminal proceedings in the matter took priority. He added that the whistle-blower did not object to the government's repeated entreaties for more time.
Last week, Lamberth denied defense motions for a new trial. But the verdict is likely to be appealed, according to lawyers who participated.
"I have a feeling we're some way away from resolution," said Charles S. Leeper, a lawyer for B.L. Harbert International, the main construction company involved in the case.
Hmmm..........Who do we know IN the WHITE HOUSE that would like to hide this? How much has been paid and to whom?
Instead, we can think about Paris and Brittany!
BOY, are we just a bunch of DUMB AMERICANS
DO not knwo what we have until we lose it and this BUSH has really progressed in that department now hasn't he?
July 3rd, 2008 5:18 pm
A Backlog Of Cases Alleging Fraud
Whistle-Blower Suits Languish at Justice
By Carrie Johnson / Washington Post
More than 900 cases alleging that government contractors and drugmakers have defrauded taxpayers out of billions of dollars are languishing in a backlog that has built up over the past decade because the Justice Department cannot keep pace with the surge in charges brought by whistle-blowers, according to lawyers involved in the disputes.
The issue is drawing renewed interest among lawmakers and nonprofit groups because many of the cases involve the wars in Iraq and Afghanistan, rising health-care payouts, and privatization of government functions -- all of which offer rich new opportunities to swindle taxpayers.
Since 2001, 300 to 400 civil cases have been filed each year by employees charging that their companies defrauded the government. But under the cumbersome process that governs these cases, Justice Department lawyers must review them under seal, and whistle-blowers routinely wait 14 months or longer just to learn whether the department will get involved. The government rejects about three-quarters of the cases it receives, saying that the vast majority have little merit.
Disputes can stay buried for years more while the government investigates the allegations.
"Even if no new cases are filed, it might take 10 years for the Department of Justice to clear its desk. Cases in the backlog represent a lot of money being left on the table," said Patrick Burns, a spokesman for Taxpayers Against Fraud, which advocates for Justice to receive more funding to support cases by whistle-blowers and their attorneys.
Supporters of federal intervention in the cases say the dividends are substantial: In recent years, verdicts and settlements have returned nearly $13 billion to the U.S. government.
At issue in most of the cases is whether companies knowingly sold defective products or overcharged federal agencies for items sold at home or offered to U.S. troops overseas. Under the Civil War-era False Claims Act, workers who file lawsuits alleging such schemes cannot discuss them or even disclose their existence until Justice decides whether to step in.
By its own account, the 75-lawyer unit in Washington that reviews the sensitive lawsuits is overloaded and understaffed. Only about 100 cases a year are investigated by the team, which works out of the commercial litigation branch of Justice's civil division.
Critics argue that the delays are at least partly the result of foot-dragging by Justice and the federal agencies whose position it represents, especially in the touchy area of suppliers that may have overbilled the government for equipment, food and other items used by troops in Iraq and Afghanistan.
Justice lawyers have rejected about 19 cases involving contractor fraud in Iraq and Afghanistan, registering five settlements that resulted in $16 million, officials said. Government officials said this week that they are considering whether to dive into 32 more whistle-blower cases involving Iraq or the Middle East.
"It's just flatly absurd for us to be five years into this war" with so few public cases, said Alan Grayson, a whistle-blower lawyer in Florida who has criticized the Justice effort and who is running for Congress as a Democrat.
In a statement, Justice spokesman Charles Miller said that career lawyers and supervisors base their determinations on merit, not on political sensitivities. "Our decisions to intervene or decline in cases involving Iraq and the Middle East are entirely consistent with our record in [whistle-blower] cases generally," he said.
Help from Justice greatly enhances the chances that a complicated fraud scheme can be unraveled, lawyers say. And department statistics show that cases Justice turns away win paltry, if any, financial recoveries.
Key lawmakers have called on Justice to make false-claims investigations a priority.
"Whistle-blowers are the key to the secrets locked in closets throughout the federal bureaucracy and government contractors," said Sen. Charles E. Grassley (R-Iowa). "These patriotic Americans stick their necks out, against all odds, to help the federal government pursue fraud and save taxpayers tens of billions of dollars that would otherwise be lost."
Last month, Deputy Assistant Attorney General Michael F. Hertz told Congress that "the number and increased complexity of the fraud schemes presented to the department, combined with the volume of cases now under review, certainly present challenges."
Among the largest false-claims cases to date are a $650 million settlement earlier this year by drugmaker Merck in connection with an alleged failure to repay Medicaid rebates; a $515 million deal with Bristol-Myers Squibb to cover illegal drug pricing and marketing; and a $98 million agreement with software maker Oracle over pricing.
If their claims are successful, whistle-blowers can receive a hefty slice of the settlements or verdicts, sometimes as much as 20 percent of the award. A former Merck sales manager collected $68 million earlier this year for his role in exposing an alleged drug-pricing scheme.
Even bigger lawsuits containing potentially explosive allegations are waiting in the wings. The vast majority, more than 500 cases, involve the health-care and pharmaceutical industries and often involve Medicare and Medicaid funds.
Only a few hints of the Iraq and Afghanistan disputes have erupted publicly. One is a suit filed by two former employees of Custer Battles, a defense contracting company in Fairfax. The workers accused the company of inflating expenses on a contract it won to replace the Iraqi currency. After a three-week trial in 2006, a jury found in favor of the plaintiffs and awarded them $10 million. But U.S. District Judge T.S. Ellis III later tossed out the case, ruling that the money at issue, controlled in the early years of the Iraq conflict by the Coalition Provisional Authority, belonged to the Iraqi government, not U.S. taxpayers.
Justice declined the whistle-blowers' request to intervene before the case went to trial, plaintiffs' lawyers said. The government eventually weighed in with a court brief on behalf of the whistle-blowers when the case was appealed.
Frederick M. Morgan Jr., a Cincinnati lawyer who represents whistle-blowers, said that the numbers of lawyers willing to take on cases involving defense contractors has dwindled, in part because of Justice's slow decisions.
One of Morgan's lawsuits, against contractors hired by the Navy to build nuclear submarines and an Ohio company that manufactured submarine valves, took five years to resolve.
Another case, involving the manufacture of the F-22 fighter, was filed in early 1999. It was late 2006 before Justice decided not to intervene. The case is now in active litigation.
"The impact of a 7 1/2 -year delay in the litigation of a case is difficult to quantify but impossible to discount," Morgan said.
Whistle-blower lawyers say other factors can contribute to long delays, including the difficulty in investigating claims in war-torn areas and complications that arise when military officials contend that technology or other products at issue in the lawsuits are classified. In addition, Justice lawyers who handle civil cases often cannot proceed until authorities decide whether a case merits criminal prosecution, the lawyers said.
Even when older cases are pushed into the open, the passage of time can present courtroom challenges.
Last year, a D.C. jury awarded whistle-blower Richard Miller more than $30 million, a figure that now-Chief Judge Royce C. Lamberth tripled to $90 million. But in the dozen years since the suit was filed, witnesses' memories of events had dimmed and the U.S. Agency for International Development had tossed its investigative files.
The judge blasted civil division lawyers for "doing virtually nothing" to follow up for four years after Miller brought forward allegations in 1995 about bid rigging on construction contracts in Egypt. The delays meant "loss of evidence, fading memories, disappearance of documents," he wrote.
Justice spokesman Miller said that the civil case was stalled for years because criminal proceedings in the matter took priority. He added that the whistle-blower did not object to the government's repeated entreaties for more time.
Last week, Lamberth denied defense motions for a new trial. But the verdict is likely to be appealed, according to lawyers who participated.
"I have a feeling we're some way away from resolution," said Charles S. Leeper, a lawyer for B.L. Harbert International, the main construction company involved in the case.
Woman pleads guilty to health care fraud
A Severna Park woman pleaded guilty in federal court to health care fraud yesterday for billing for medical services she did not provide, according to the U.S. attorney's office.
Virginia Vought Acree, 49, a state-licensed clinical specialist in child and adolescent psychiatric and mental health nursing, admitted to falsely billing for services she did not provide on hundreds of occasions from January 2003 to November 2007, prosecutors said. She filed fraudulent insurance claims to collect more than $200,000 from the government and private health care plans.
At times, Acree billed for face-to-face psychotherapy services at the same time she was on vacation in other states or countries, or attending out-of-town conferences, prosecutors said.
Sentencing is set for Oct. 7. Acree could get a maximum sentence of 10 years in prison and a $250,000 fine, prosecutors said.
Virginia Vought Acree, 49, a state-licensed clinical specialist in child and adolescent psychiatric and mental health nursing, admitted to falsely billing for services she did not provide on hundreds of occasions from January 2003 to November 2007, prosecutors said. She filed fraudulent insurance claims to collect more than $200,000 from the government and private health care plans.
At times, Acree billed for face-to-face psychotherapy services at the same time she was on vacation in other states or countries, or attending out-of-town conferences, prosecutors said.
Sentencing is set for Oct. 7. Acree could get a maximum sentence of 10 years in prison and a $250,000 fine, prosecutors said.
Monday, July 28, 2008
AIS's Report on Medicare Compliance (RMC) - Hospitals may be able to fend off recovery audit contractor ....
No wonder FRAUD is "OUT OF CONTROL"!!!
Many Hospital Claims Denials by Recovery Audit Contractors Are Overturned, as Process Itself Is Questioned
Hospitals may be able to fend off recovery audit contractor (RAC) claims denials for medically unnecessary admissions or services because some of them have been overturned, experts tell RMC.
Washington, DC (PRWEB) July 17, 2008 -- AIS's Report on Medicare Compliance (RMC) - Hospitals may be able to fend off recovery audit contractor (RAC) claims denials for medically unnecessary admissions or services because some of them have been overturned, experts tell RMC. If RACs are too quick to reject admissions because they don't meet screening criteria (e.g., InterQual) without looking at the entire medical record, hospitals may be able to reverse them. The best approach, however, is to have an effective up-front process that provides ample documentation of the decision making behind an inpatient admission as described in the Medicare Benefit Policy Manual. To read the full story, go to http://www.aishealth.com/Bnow/hbd070308.html.
Meanwhile, there's evidence that RACs may rush to judgment about some inpatient admissions, physician, Robert Corrato, M.D., CEO of Executive Health Resources tells RMC. For example, CMS appeals contractors and administrative law judges overturned more than 1,000 RAC claims denials appealed by hospitals in four states toward the end of the RAC pilot, which wrapped up in March, says Corrato, whose organization helped the hospitals mount appeals. The hospitals were able to prove that the admissions and/or services were medically necessary, he says.
However, CMS says that only 5% of RAC determinations were overturned on appeal from the beginning of the pilot through Oct. 31, 2007. "CMS does not expect this number to change significantly once the evaluation report of the three-year demonstration is released," a CMS official tells RMC. About 40% of the overpayments identified by RACs were based on their assertions that the services lacked medical necessity. But Corrato notes that "when the 5% figure was computed, very few cases had advanced to the third level of appeal (the ALJ)" and "CMS's own statistics...indicate that 44.2% of appealed cases were decided in favor of the provider."
This article has been excerpted from AIS's Report on Medicare Compliance (RMC). To access the story in its entirety, visit http://www.aishealth.com/Bnow/hbd070308.html.
About Report on Medicare Compliance
Published by Atlantic Information Services, Report on Medicare Compliance is written by veteran compliance editor and reporter, Nina Youngstrom. Since 1992, this award-winning weekly newsletter has been the industry's #1 source of compliance news and strategies ... on medical necessity, physician payments, DRG coding, quality of care, observation billing, Stark and more.
Many Hospital Claims Denials by Recovery Audit Contractors Are Overturned, as Process Itself Is Questioned
Hospitals may be able to fend off recovery audit contractor (RAC) claims denials for medically unnecessary admissions or services because some of them have been overturned, experts tell RMC.
Washington, DC (PRWEB) July 17, 2008 -- AIS's Report on Medicare Compliance (RMC) - Hospitals may be able to fend off recovery audit contractor (RAC) claims denials for medically unnecessary admissions or services because some of them have been overturned, experts tell RMC. If RACs are too quick to reject admissions because they don't meet screening criteria (e.g., InterQual) without looking at the entire medical record, hospitals may be able to reverse them. The best approach, however, is to have an effective up-front process that provides ample documentation of the decision making behind an inpatient admission as described in the Medicare Benefit Policy Manual. To read the full story, go to http://www.aishealth.com/Bnow/hbd070308.html.
Meanwhile, there's evidence that RACs may rush to judgment about some inpatient admissions, physician, Robert Corrato, M.D., CEO of Executive Health Resources tells RMC. For example, CMS appeals contractors and administrative law judges overturned more than 1,000 RAC claims denials appealed by hospitals in four states toward the end of the RAC pilot, which wrapped up in March, says Corrato, whose organization helped the hospitals mount appeals. The hospitals were able to prove that the admissions and/or services were medically necessary, he says.
However, CMS says that only 5% of RAC determinations were overturned on appeal from the beginning of the pilot through Oct. 31, 2007. "CMS does not expect this number to change significantly once the evaluation report of the three-year demonstration is released," a CMS official tells RMC. About 40% of the overpayments identified by RACs were based on their assertions that the services lacked medical necessity. But Corrato notes that "when the 5% figure was computed, very few cases had advanced to the third level of appeal (the ALJ)" and "CMS's own statistics...indicate that 44.2% of appealed cases were decided in favor of the provider."
This article has been excerpted from AIS's Report on Medicare Compliance (RMC). To access the story in its entirety, visit http://www.aishealth.com/Bnow/hbd070308.html.
About Report on Medicare Compliance
Published by Atlantic Information Services, Report on Medicare Compliance is written by veteran compliance editor and reporter, Nina Youngstrom. Since 1992, this award-winning weekly newsletter has been the industry's #1 source of compliance news and strategies ... on medical necessity, physician payments, DRG coding, quality of care, observation billing, Stark and more.
Saturday, July 26, 2008
America’s Health Insurance Plans , Patient Privacy Rights said the revised bill is being reviewed and declined comment ....
House Energy and Commerce Committee Chair John Dingell (D-Mich.) and ranking member Joe Barton (R-Texas) on Tuesday released a revised version of a bill (HR 6357) that aims to promote nationwide adoption of an electronic health record system, CongressDaily reports. According to CongressDaily, the lawmakers “substantially changed the information-sharing and privacy provisions of their proposal” following “concerns from stakeholders in the health care, high-tech and consumer advocacy arenas.” The bill is scheduled for a full committee mark up on Wednesday (Noyes, CongressDaily, 7/22).
Under the revised bill, patients would give their consent only once to health care companies that want to access health care records without identifying information for HHS-approved purposes, such as hospital audits or fraud and abuse allegations. The bill previously would have required patient consent each time the records were accessed (Young, The Hill, 7/22). According to the revised bill, the patient consent provision would be implemented two years after the bill is enacted, and HHS would be required to develop “reasonable and workable” rules to implement the provision.
The original version of the bill also would have required health care providers to notify patients of any unauthorized acquisition, access or disclosure of their health care information. The revised version states that a “good faith” disclosure, such as a mislabeled letter with a wrong address, would not be considered a breach.
Other revised provisions in the bill would:
Prohibit the sale of patients’ records without consent unless it is necessary for treatment or to receive payment for treatment;
Change existing federal privacy laws to allow for the provision of a no-cost digital copy of an individual’s medical record;
Strengthen language to ban direct and indirect payments to providers who advertise health care products to patients without permission; and
Require the HHS Office of Civil Rights to launch a formal investigation of complaints and allow the office to impose fines for violations deemed “willful neglect” (Noyes, CongressDaily, 7/22).
Comments
House Energy and Commerce Subcommittee on Health ranking member Nathan Deal (R-Ga.) said the bill could advance on Wednesday. Deal said, “I think we worked out most of the big issues, barring amendments that come in and change that balance,” adding, “Assuming the mark up goes fairly smoothly this week … we probably would see it maybe even in the form of a suspension on the floor” (Armstrong, CQ Today, 7/22).
Mary Grealy, president of the Healthcare Leadership Council — who on Monday sent a letter to Dingell and Barton stating her concerns about the proposed bill’s effect on the Confidentiality Coalition — said, “They did make improvements in those provisions we had some concerns about, so I do feel like we’re making progress.” However, she added, “Do I think they have completely addressed all the issues? No” (The Hill, 7/22).
A spokesperson for America’s Health Insurance Plans said the provision that would allow patients to access their medical records and require them to provide consent for third-party access could restrict health care providers from developing wellness, disease management, quality assurance and other essential programs (CongressDaily, 7/22). A spokesperson for Patient Privacy Rights said the revised bill is being reviewed and declined comment (The Hill, 7/22).
Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.
Under the revised bill, patients would give their consent only once to health care companies that want to access health care records without identifying information for HHS-approved purposes, such as hospital audits or fraud and abuse allegations. The bill previously would have required patient consent each time the records were accessed (Young, The Hill, 7/22). According to the revised bill, the patient consent provision would be implemented two years after the bill is enacted, and HHS would be required to develop “reasonable and workable” rules to implement the provision.
The original version of the bill also would have required health care providers to notify patients of any unauthorized acquisition, access or disclosure of their health care information. The revised version states that a “good faith” disclosure, such as a mislabeled letter with a wrong address, would not be considered a breach.
Other revised provisions in the bill would:
Prohibit the sale of patients’ records without consent unless it is necessary for treatment or to receive payment for treatment;
Change existing federal privacy laws to allow for the provision of a no-cost digital copy of an individual’s medical record;
Strengthen language to ban direct and indirect payments to providers who advertise health care products to patients without permission; and
Require the HHS Office of Civil Rights to launch a formal investigation of complaints and allow the office to impose fines for violations deemed “willful neglect” (Noyes, CongressDaily, 7/22).
Comments
House Energy and Commerce Subcommittee on Health ranking member Nathan Deal (R-Ga.) said the bill could advance on Wednesday. Deal said, “I think we worked out most of the big issues, barring amendments that come in and change that balance,” adding, “Assuming the mark up goes fairly smoothly this week … we probably would see it maybe even in the form of a suspension on the floor” (Armstrong, CQ Today, 7/22).
Mary Grealy, president of the Healthcare Leadership Council — who on Monday sent a letter to Dingell and Barton stating her concerns about the proposed bill’s effect on the Confidentiality Coalition — said, “They did make improvements in those provisions we had some concerns about, so I do feel like we’re making progress.” However, she added, “Do I think they have completely addressed all the issues? No” (The Hill, 7/22).
A spokesperson for America’s Health Insurance Plans said the provision that would allow patients to access their medical records and require them to provide consent for third-party access could restrict health care providers from developing wellness, disease management, quality assurance and other essential programs (CongressDaily, 7/22). A spokesperson for Patient Privacy Rights said the revised bill is being reviewed and declined comment (The Hill, 7/22).
Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.
.....problem that costs the healthcare system an estimated $60 billion a year at the lowest estimate, and perhaps as much as $200 billion a year,.....
Healthcare fraud doesn’t even get a mention in the recently released government plan for creating a nationwide health information network.
REALLY? My same sentiments regarding the CAMPAIGN and FIXING the HEALTHCARE SYSTEM in this country.
Tackle fraud issue now, IT leaders advise
Jul 25th, 2008 | By Vantage Technology | Category: Healthcare IT
Healthcare fraud doesn’t even get a mention in the recently released government plan for creating a nationwide health information network.
Donald W. Simborg, MD, headed a team that worked on the problem of fraud for the Office of the National Coordinator. It’s a problem that costs the healthcare system an estimated $60 billion a year at the lowest estimate, and perhaps as much as $200 billion a year, Simborg told an audience at the 3rd Annual Leadership Summit on The Road to Interoperability, held in Boston earlier this week
Simborg chaired a follow-up panel that came up with a list of 14 specific recommendations that could be built into the review process used by the Certification Commission for Healthcare Information Technology.
“So what happened to our recommendations?” Simborg asked. “Well, it got a lot of push-back.”
On some level, Simborg expected resistance. Requiring fraud protections would perhaps slow the already snail-like pace of EMR adoption - at 4 percent, compared with 90 percent in every other industrialized country, according to David Bates, MD, medical director at the Harvard University-affiliated Partners HealthCare in Boston.
“What I didn’t expect was that (the Office of the National Coordinator) would totally drop fraud management from its plan,” Simborg said. “What I can’t understand is why we don’t try to solve this problem.”
“What I find astounding,” said Reed Gelzer, MD, a member of CCHIT’s privacy and compliance panel and co-founder of Advocates for Documentation Integrity and Compliance, “we are essentially suggesting our healthcare organizations adopt systems for which there are virtually no standards and minimal certifications. Where’s the discussion of the fact that we are killing 50,000 to 100,000 people a year?”
Simborg, who has been a vocal supporter of EHR adoption for more than 30 years, is a co-founder and member of Health Level 7, a founding member of the American College of Medical Informatics and a board member of the Foundation on Research and Education at the American Health Information Management Association (AHIMA).
In his view, the focus on promoting adoption, which goes back to President George W. Bush’s mention of electronic medical records in his State of the Union Address in 2004, might prove fruitless.
“Unless the focus changes,” he said, “adoption of electronic health records will lead to higher healthcare costs without much benefit. Without proactive fraud management, whatever the problem is will be much greater in an electronic environment.”
Beyond that, there are other issues.
The physician savings derived from electronic health records most often come from coding increases - what Simborg called “E&M code creep.” The E&M stands for evaluation and management.
“We need to have fundamental changes in how we pay physicians,” Simborg said.
While electronic health records provide a legitimate way for physicians to speed up their documentation, they also increase costs, he said.
He noted that when he developed a commercial EHR for oncologists, “our customers had an increase in billing that provided ROI in two years. More than half came from coding increases.”
Simborg suggests that adoption per se is not the goal.
“If driving value means slower adoption, that’s OK,” he said.
He recommends continuing “what we do right:”
Work on interoperability and certification;
Eliminate E&M payments based on volume of documentation;
Promote P4P models;
Build in decision-support and add incentives based on documented behavior change (over time, though, even that can be gamed, he said);
And tackle the issue of fraud management.
“Clearly we have to put fraud management in there somewhere,” he said. “The elephant has to be slain.”
“The issue is patient literacy,” said Charles Jaffe, MD, chief executive officer of HL7. “When we put down our list of to-dos, let’s make sure there are others in the equation besides providers.”
REALLY? My same sentiments regarding the CAMPAIGN and FIXING the HEALTHCARE SYSTEM in this country.
Tackle fraud issue now, IT leaders advise
Jul 25th, 2008 | By Vantage Technology | Category: Healthcare IT
Healthcare fraud doesn’t even get a mention in the recently released government plan for creating a nationwide health information network.
Donald W. Simborg, MD, headed a team that worked on the problem of fraud for the Office of the National Coordinator. It’s a problem that costs the healthcare system an estimated $60 billion a year at the lowest estimate, and perhaps as much as $200 billion a year, Simborg told an audience at the 3rd Annual Leadership Summit on The Road to Interoperability, held in Boston earlier this week
Simborg chaired a follow-up panel that came up with a list of 14 specific recommendations that could be built into the review process used by the Certification Commission for Healthcare Information Technology.
“So what happened to our recommendations?” Simborg asked. “Well, it got a lot of push-back.”
On some level, Simborg expected resistance. Requiring fraud protections would perhaps slow the already snail-like pace of EMR adoption - at 4 percent, compared with 90 percent in every other industrialized country, according to David Bates, MD, medical director at the Harvard University-affiliated Partners HealthCare in Boston.
“What I didn’t expect was that (the Office of the National Coordinator) would totally drop fraud management from its plan,” Simborg said. “What I can’t understand is why we don’t try to solve this problem.”
“What I find astounding,” said Reed Gelzer, MD, a member of CCHIT’s privacy and compliance panel and co-founder of Advocates for Documentation Integrity and Compliance, “we are essentially suggesting our healthcare organizations adopt systems for which there are virtually no standards and minimal certifications. Where’s the discussion of the fact that we are killing 50,000 to 100,000 people a year?”
Simborg, who has been a vocal supporter of EHR adoption for more than 30 years, is a co-founder and member of Health Level 7, a founding member of the American College of Medical Informatics and a board member of the Foundation on Research and Education at the American Health Information Management Association (AHIMA).
In his view, the focus on promoting adoption, which goes back to President George W. Bush’s mention of electronic medical records in his State of the Union Address in 2004, might prove fruitless.
“Unless the focus changes,” he said, “adoption of electronic health records will lead to higher healthcare costs without much benefit. Without proactive fraud management, whatever the problem is will be much greater in an electronic environment.”
Beyond that, there are other issues.
The physician savings derived from electronic health records most often come from coding increases - what Simborg called “E&M code creep.” The E&M stands for evaluation and management.
“We need to have fundamental changes in how we pay physicians,” Simborg said.
While electronic health records provide a legitimate way for physicians to speed up their documentation, they also increase costs, he said.
He noted that when he developed a commercial EHR for oncologists, “our customers had an increase in billing that provided ROI in two years. More than half came from coding increases.”
Simborg suggests that adoption per se is not the goal.
“If driving value means slower adoption, that’s OK,” he said.
He recommends continuing “what we do right:”
Work on interoperability and certification;
Eliminate E&M payments based on volume of documentation;
Promote P4P models;
Build in decision-support and add incentives based on documented behavior change (over time, though, even that can be gamed, he said);
And tackle the issue of fraud management.
“Clearly we have to put fraud management in there somewhere,” he said. “The elephant has to be slain.”
“The issue is patient literacy,” said Charles Jaffe, MD, chief executive officer of HL7. “When we put down our list of to-dos, let’s make sure there are others in the equation besides providers.”
$156,000 in restitution , and PROBATION!!
Health care fraud gets Washington County man three-year probationBy The Tribune-Review
Saturday, July 26, 2008
A Washington County man was sentenced in federal court Friday to three years' probation for health care fraud.
U.S. District Judge Gary L. Lancaster placed John Slimick, 49, of New Eagle on house arrest for six months. Slimick was ordered to pay $156,000 in restitution to Highmark Blue Cross Blue Shield and to perform 120 hours of community service.
Slimick is one of more than a dozen people convicted of taking kickbacks from former Lower Burrell chiropractor Douglas Henderson, who billed the insurance company for treatment never performed. Henderson, who submitted more than $7 million in false claims, is awaiting sentencing.
Saturday, July 26, 2008
A Washington County man was sentenced in federal court Friday to three years' probation for health care fraud.
U.S. District Judge Gary L. Lancaster placed John Slimick, 49, of New Eagle on house arrest for six months. Slimick was ordered to pay $156,000 in restitution to Highmark Blue Cross Blue Shield and to perform 120 hours of community service.
Slimick is one of more than a dozen people convicted of taking kickbacks from former Lower Burrell chiropractor Douglas Henderson, who billed the insurance company for treatment never performed. Henderson, who submitted more than $7 million in false claims, is awaiting sentencing.
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