Posted: Dec 16, 2008 05:18 PM CST
NASHVILLE (WATE) -- A man and woman from Athens have been charged with 2 from Athens charged with TennCare fraud
Posted: Dec 16, 2008 05:18 PM CST
NASHVILLE (WATE) -- A man and woman from Athens have been charged with TennCare fraud in separate cases.
John V. Davis, 25, is charged with three counts of using TennCare to get controlled substances by doctor shopping.
According to the indictment, Davis failed to disclose to his doctor that he'd seen other doctors within a 30-day period, receiving prescriptions for the painkillers Oxycodone and Hydrocodone.
Investigators say Davis received a prescription for Oxycodone during a visit to a hospital emergency room, which was paid for by TennCare.
They also say Davis used TennCare twice to pay for prescriptions for Hydrocodone.
Kristie Smithers, 31, is charged with three counts of TennCare fraud for using it to pay for fake prescriptions.
Smithers is accused of using TennCare to pay for fake prescriptions written for Hydrocodone three times.
If convicted, each could each spend up to two years per charge in prison.
Friday, December 19, 2008
OIG Releases Reports on Hospital Adverse Events and State Reporting Systems
December 16, 2008
OIG Releases Reports on Hospital Adverse Events and State Reporting SystemsOn December 16, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) released a report entitled "Adverse Events in Hospitals: Overview of Key Issues."
The Tax Relief and Health Care Act of 2006 (Act) mandates that the OIG report to Congress regarding the incidence of "never events" among Medicare beneficiaries, payment by Medicare or beneficiaries for services furnished in connection with such events, and the process that the Centers for Medicare & Medicaid Services uses to identify events and deny payment. According to the OIG, this report is one in a series to fulfill the requirements of the Act.
In this report, the OIG identifies 7 issues critical to understanding adverse events in hospitals. In brief, the 7 issues can be described as follows:
Estimates of the incidence of adverse events in hospitals vary widely and measurement is difficult.
Nonpayment policies for adverse events are gaining in prominence and are viewed as a powerful incentive to reduce incidence but raise potential drawbacks.
Hospitals rely on staff and managers to report adverse events internally, but barriers can inhibit reporting.
Hospitals report adverse events to various oversight entities, although stakeholders suspect substantial underreporting.
Public disclosure of adverse events can benefit patients but also raises legal concerns for patients and providers.
Information to help prevent adverse events is widely available, but some hospitals and clinicians may be slow to adopt or routinely apply recommended practices.
Interviews and literature reveal strategies that may accelerate progress in reducing the incidence of adverse events in hospitals.
On December 16, 2008, the OIG has also released a related report entitled "Adverse Events in Hospitals: State Reporting Systems" in which the OIG identifies and describes state adverse event reporting systems and how states use the reported information. In brief, the OIG reports the following:
As of January 2008, 26 states had hospital adverse event reporting systems and another state had taken action to develop one.
Reporting systems varied in terms of what events were reported, criteria used for selection, and type of information reported.
Most states with systems reported having mechanisms to identify underreporting and strategies to improve reporting.
23 states reported using data to hold individual hospitals accountable and 18 states reported using data to promote learning and prevent adverse events.
In this report, the OIG concludes that state systems are disparate making state adverse event reporting systems data unsuitable for use in the aggregate to identify national incidence and trends. However, the OIG reports that most states use the reported data in similar ways. For instance, states use reports to assess individual hospitals' responses to adverse events, and to promote learning and prevent adverse events.
For purposes of the OIG reports, the OIG expanded beyond the term "never events" to address "adverse events," which describe patient harm resulting from medical ca
http://medicareupdate.typepad.com/medicare_update/2008/12/oigadverseeventreports.html
OIG Releases Reports on Hospital Adverse Events and State Reporting SystemsOn December 16, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) released a report entitled "Adverse Events in Hospitals: Overview of Key Issues."
The Tax Relief and Health Care Act of 2006 (Act) mandates that the OIG report to Congress regarding the incidence of "never events" among Medicare beneficiaries, payment by Medicare or beneficiaries for services furnished in connection with such events, and the process that the Centers for Medicare & Medicaid Services uses to identify events and deny payment. According to the OIG, this report is one in a series to fulfill the requirements of the Act.
In this report, the OIG identifies 7 issues critical to understanding adverse events in hospitals. In brief, the 7 issues can be described as follows:
Estimates of the incidence of adverse events in hospitals vary widely and measurement is difficult.
Nonpayment policies for adverse events are gaining in prominence and are viewed as a powerful incentive to reduce incidence but raise potential drawbacks.
Hospitals rely on staff and managers to report adverse events internally, but barriers can inhibit reporting.
Hospitals report adverse events to various oversight entities, although stakeholders suspect substantial underreporting.
Public disclosure of adverse events can benefit patients but also raises legal concerns for patients and providers.
Information to help prevent adverse events is widely available, but some hospitals and clinicians may be slow to adopt or routinely apply recommended practices.
Interviews and literature reveal strategies that may accelerate progress in reducing the incidence of adverse events in hospitals.
On December 16, 2008, the OIG has also released a related report entitled "Adverse Events in Hospitals: State Reporting Systems" in which the OIG identifies and describes state adverse event reporting systems and how states use the reported information. In brief, the OIG reports the following:
As of January 2008, 26 states had hospital adverse event reporting systems and another state had taken action to develop one.
Reporting systems varied in terms of what events were reported, criteria used for selection, and type of information reported.
Most states with systems reported having mechanisms to identify underreporting and strategies to improve reporting.
23 states reported using data to hold individual hospitals accountable and 18 states reported using data to promote learning and prevent adverse events.
In this report, the OIG concludes that state systems are disparate making state adverse event reporting systems data unsuitable for use in the aggregate to identify national incidence and trends. However, the OIG reports that most states use the reported data in similar ways. For instance, states use reports to assess individual hospitals' responses to adverse events, and to promote learning and prevent adverse events.
For purposes of the OIG reports, the OIG expanded beyond the term "never events" to address "adverse events," which describe patient harm resulting from medical ca
http://medicareupdate.typepad.com/medicare_update/2008/12/oigadverseeventreports.html
Thursday, December 18, 2008
'...Six strategies for waste elimination: ...'
Eliminating Waste in Health Care
The ability to eliminate unnecessary cost is absolutely critical to health care industry. Total spending was $2.3 TRILLION in 2007, or $7600 per person [1]. Total health care spending represented 16 percent of the gross domestic product (GDP). U.S. health care spending is expected to increase at approximately 7% levels for the next decade reaching $4.2 TRILLION in 2016, or 20 percent of GDP [1].
In 2007, employer health insurance premiums increased by 6.1 percent - two times the rate of inflation [2]. The annual premium for an employer health plan covering a family of four averaged nearly $12,100. The annual premium for single coverage averaged over $4,400 [2]. Experts agree that US health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.
So, how health care system can eliminate waste? The results from my research about medication delivery systems conducted over two years at one community hospital provide some answers to this question.
The results are:
• Fifty two out of sixty three nurses (82.53%) highlighted poor training for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
• Fifty five out of sixty three nurses (87.3%) reported confusion about their role expectation with respect to medication error reporting and prevention. All technicians stated similar concerns.
• Fifty four out of sixty three nurses (85.7%) specified lack of feedback as important factor affecting their psychological safety towards error reporting and prevention efforts. Four out of 6 technicians (66.67%) pointed to the same issue.
• All nurses and all technicians (100%) highlighted productivity pressures as the most stress-generating factor on their daily work averting them from medication error reporting and prevention.
• Forty four out of sixty three nurses (69.8%) and three technicians (50%) suggested group behavior influence as another major factor behind poor medication error reporting and prevention.
• Forty eight out of sixty three nurses (76.19%) indicated difficulties with utilizing the mechanisms for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
Therefore, based on the ‘voice’ from the front line staff, I propose the following six strategies for waste elimination:
1) First, healthcare organizations should recognize the growing need to advance the understanding about healthcare delivery systems, unnecessary waste, as well as Quality Improvement (QI) programs by health care professionals. This can be done via continuum education training on systems and QI.
2) Second, health care organizations should start recognizing their frontline professionals as assets rather than costs. It is everybody’s job to eliminate waste and to do improvements. Therefore, the role expectation with respect to waste elimination and quality improvement should be well communicated to all frontline employees and continuously supported by managers and administrators.
3) Third, organization-wide and constructive feedback to frontline health care professionals about QI needs to be provided on a continuous basis. My research found that health care professionals who felt neglected and under-informed regarding the changes often responded with low motivation and discouragement towards QI efforts.
4) Fourth, the productivity pressures, often mentioned by frontline workers as one of the major contributing factors causing the low QI efforts, should be offset by redesigning systems that minimize the unnecessary waste during daily work. This should allow health care professional to devote more time to continuous improvement efforts.
5) Fifth, to remove the undesired group behavior, managers should physically spend more time and effort to establish and support a culture of excellence with high commitment to patient safety, waste elimination and QI.
6) Finally, all unit managers should provide active leadership at the unit floor for promoting standardized behavior with respect to procedural compliance. The goal is to eliminate the variability in the process by creating a culture that values procedural compliance. In additions, promoting procedural compliance by the manager at the unit floor can increase the rate of error recognition and QI efforts via root-cause problem solving, enhance the manager’s reputation for patient safety, and increase the confidence of health care professionals in her/his leadership abilities/skills.
I hope that the proposed implications and discussions will help health care organizations to achieve satisfactory improvement in waste elimination efforts. In addition, I believe that the proposed insights into this area have potential to enhance professional development of health care managers and professionals.
1. Poisal, J.A., et al, Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact. Health Affairs (21 February 2007): W242-253.
2. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2007 Annual Survey. 11 September 2006. http://www.kff.org/insurance/7672/index.cfm
The ability to eliminate unnecessary cost is absolutely critical to health care industry. Total spending was $2.3 TRILLION in 2007, or $7600 per person [1]. Total health care spending represented 16 percent of the gross domestic product (GDP). U.S. health care spending is expected to increase at approximately 7% levels for the next decade reaching $4.2 TRILLION in 2016, or 20 percent of GDP [1].
In 2007, employer health insurance premiums increased by 6.1 percent - two times the rate of inflation [2]. The annual premium for an employer health plan covering a family of four averaged nearly $12,100. The annual premium for single coverage averaged over $4,400 [2]. Experts agree that US health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.
So, how health care system can eliminate waste? The results from my research about medication delivery systems conducted over two years at one community hospital provide some answers to this question.
The results are:
• Fifty two out of sixty three nurses (82.53%) highlighted poor training for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
• Fifty five out of sixty three nurses (87.3%) reported confusion about their role expectation with respect to medication error reporting and prevention. All technicians stated similar concerns.
• Fifty four out of sixty three nurses (85.7%) specified lack of feedback as important factor affecting their psychological safety towards error reporting and prevention efforts. Four out of 6 technicians (66.67%) pointed to the same issue.
• All nurses and all technicians (100%) highlighted productivity pressures as the most stress-generating factor on their daily work averting them from medication error reporting and prevention.
• Forty four out of sixty three nurses (69.8%) and three technicians (50%) suggested group behavior influence as another major factor behind poor medication error reporting and prevention.
• Forty eight out of sixty three nurses (76.19%) indicated difficulties with utilizing the mechanisms for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
Therefore, based on the ‘voice’ from the front line staff, I propose the following six strategies for waste elimination:
1) First, healthcare organizations should recognize the growing need to advance the understanding about healthcare delivery systems, unnecessary waste, as well as Quality Improvement (QI) programs by health care professionals. This can be done via continuum education training on systems and QI.
2) Second, health care organizations should start recognizing their frontline professionals as assets rather than costs. It is everybody’s job to eliminate waste and to do improvements. Therefore, the role expectation with respect to waste elimination and quality improvement should be well communicated to all frontline employees and continuously supported by managers and administrators.
3) Third, organization-wide and constructive feedback to frontline health care professionals about QI needs to be provided on a continuous basis. My research found that health care professionals who felt neglected and under-informed regarding the changes often responded with low motivation and discouragement towards QI efforts.
4) Fourth, the productivity pressures, often mentioned by frontline workers as one of the major contributing factors causing the low QI efforts, should be offset by redesigning systems that minimize the unnecessary waste during daily work. This should allow health care professional to devote more time to continuous improvement efforts.
5) Fifth, to remove the undesired group behavior, managers should physically spend more time and effort to establish and support a culture of excellence with high commitment to patient safety, waste elimination and QI.
6) Finally, all unit managers should provide active leadership at the unit floor for promoting standardized behavior with respect to procedural compliance. The goal is to eliminate the variability in the process by creating a culture that values procedural compliance. In additions, promoting procedural compliance by the manager at the unit floor can increase the rate of error recognition and QI efforts via root-cause problem solving, enhance the manager’s reputation for patient safety, and increase the confidence of health care professionals in her/his leadership abilities/skills.
I hope that the proposed implications and discussions will help health care organizations to achieve satisfactory improvement in waste elimination efforts. In addition, I believe that the proposed insights into this area have potential to enhance professional development of health care managers and professionals.
1. Poisal, J.A., et al, Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact. Health Affairs (21 February 2007): W242-253.
2. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2007 Annual Survey. 11 September 2006. http://www.kff.org/insurance/7672/index.cfm
"...recruited homeless people on Medicare and Medi-Cal for hospitalization."
The former head of City of Angels Medical Center pleaded guilty today to his part in a scheme that used L.A.’s Skid Row homeless to defraud Medicare and Medi-Cal. More from KPCC’s Debra Baer.
Debra Baer: Dr. Rudra Sabaratnam pleaded guilty in federal court to two felony counts of paying half-a-million dollars in illegal kickbacks for patient referrals. Prosecutors say he and a co-defendant, who also admitted guilt, recruited homeless people on Medicare and Medi-Cal for hospitalization, even though they weren’t sick. They then billed the government health programs for unnecessary medical care.
Sabaratnam agreed to pay more than $4 million in restitution to Medicare and Medi-Cal. The 64-year-old Brentwood physician faces up to 10 years in prison when he is sentenced in June.
Tools
Debra Baer: Dr. Rudra Sabaratnam pleaded guilty in federal court to two felony counts of paying half-a-million dollars in illegal kickbacks for patient referrals. Prosecutors say he and a co-defendant, who also admitted guilt, recruited homeless people on Medicare and Medi-Cal for hospitalization, even though they weren’t sick. They then billed the government health programs for unnecessary medical care.
Sabaratnam agreed to pay more than $4 million in restitution to Medicare and Medi-Cal. The 64-year-old Brentwood physician faces up to 10 years in prison when he is sentenced in June.
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Federal agents raid convalescent home headquarters
Federal agents raid convalescent home headquarters
By TONY SAAVEDRA and RONALD CAMPBELL
The Orange County Register
Wednesday, December 17, 2008
Federal agents on Wednesday raided the Mission Viejo headquarters of a national chain of convalescent homes in what company officials said appears to be an investigation into suspected Medicare fraud.
Officials from Ensign Group Inc. said the Department of Justice has been investigating the company since 2006. Greg Stapley, corporate vice president and legal counsel, said the firm may have inherited the problem from its strategy of acquiring troubled group homes.
"We take in a lot of facilities that are in trouble and turn them around," Stapley said.
The U.S. Attorney's Office in Los Angeles could not be reached for comment.
Founded in 1999, The Ensign Group owns and leases 61 convalescent centers in six states, including three in Orange County: Palm Terrace Health Care Center in Laguna Woods; Sea Cliff Health Care Center in Huntington Beach; and Victoria Health Care Center in Costa Mesa. Ensign has a total of 7,400 beds and raised $411 million in revenue in 2007.
According to documents filed by the company with the Security Exchange Commission, the Department of Justice has been looking into the billing and reimbursement practice of some of the firm's subsidiaries.
In 2007, federal attorneys in Los Angeles subpoenaed the firm's bank documents, but later rescinded the demand. The subpoena asked for financial transactions involving Ensign, 10 subsidiaries, an outside investor group and some company officers, said the SEC report.
Later that year, the U.S. Attorney's office sought a meeting with an Ensign employee regarding an investigation into Medicare claims with the federal Department of Health and Human Services Office. The request for a meeting was rescinded, according to the SEC report.
In December 2007, the firm's accounting contractor was subpoenaed and, later, another employee was contacted.
"We believe that the U.S. Attorney may be conducting parallel criminal, civil and administrative investigations involving the Ensign Group and one or more of our skilled nursing facilities," the company said in SEC documents.
The raid on Wednesday was the first formal confirmation of the federal probe.
In November 2006, the company conducted its own internal investigation into Medicare reimbursements and found that documentation was missing for $224,000 in Medicare claims, documents said. These claims have been reported to the federal government, according to SEC statements.
Contact the writer: tsaavedra@ocregister.com or 714-796-6930
By TONY SAAVEDRA and RONALD CAMPBELL
The Orange County Register
Wednesday, December 17, 2008
Federal agents on Wednesday raided the Mission Viejo headquarters of a national chain of convalescent homes in what company officials said appears to be an investigation into suspected Medicare fraud.
Officials from Ensign Group Inc. said the Department of Justice has been investigating the company since 2006. Greg Stapley, corporate vice president and legal counsel, said the firm may have inherited the problem from its strategy of acquiring troubled group homes.
"We take in a lot of facilities that are in trouble and turn them around," Stapley said.
The U.S. Attorney's Office in Los Angeles could not be reached for comment.
Founded in 1999, The Ensign Group owns and leases 61 convalescent centers in six states, including three in Orange County: Palm Terrace Health Care Center in Laguna Woods; Sea Cliff Health Care Center in Huntington Beach; and Victoria Health Care Center in Costa Mesa. Ensign has a total of 7,400 beds and raised $411 million in revenue in 2007.
According to documents filed by the company with the Security Exchange Commission, the Department of Justice has been looking into the billing and reimbursement practice of some of the firm's subsidiaries.
In 2007, federal attorneys in Los Angeles subpoenaed the firm's bank documents, but later rescinded the demand. The subpoena asked for financial transactions involving Ensign, 10 subsidiaries, an outside investor group and some company officers, said the SEC report.
Later that year, the U.S. Attorney's office sought a meeting with an Ensign employee regarding an investigation into Medicare claims with the federal Department of Health and Human Services Office. The request for a meeting was rescinded, according to the SEC report.
In December 2007, the firm's accounting contractor was subpoenaed and, later, another employee was contacted.
"We believe that the U.S. Attorney may be conducting parallel criminal, civil and administrative investigations involving the Ensign Group and one or more of our skilled nursing facilities," the company said in SEC documents.
The raid on Wednesday was the first formal confirmation of the federal probe.
In November 2006, the company conducted its own internal investigation into Medicare reimbursements and found that documentation was missing for $224,000 in Medicare claims, documents said. These claims have been reported to the federal government, according to SEC statements.
Contact the writer: tsaavedra@ocregister.com or 714-796-6930
Legal Advocacy
Supreme Court Refuses to Allow Federal Labeling Law to Shield Against Fraud/Misrepresentation Claims
The U.S. Supreme Court ruled that manufacturers of potentially dangerous products are not shielded from state consumer law merely because their products have complied with federal labeling laws. The specific product at issue in Altria Group Inc. v. Good was “light” cigarettes, but the Court is also considering this term a case that asks whether federal law preempts state product liability claims against pharmaceutical manufacturers for labeling that fails to adequately warn of a drug’s risks.
AARP filed “friend of the court” briefs in both the cigarette and the pharmaceutical case, urging the Court not to preempt state laws because doing so would limit state efforts to protect the health and welfare of their citizens -- allowing consumers who have been injured as a result of a manufacturer’s deceptive practices or faulty manufacturing without a remedy for the harm.
The dispute
Stephanie Good was a smoker who lived in Maine and favored Marlboro Lights and Cambridge Lights cigarettes, believing the marketing claims by cigarette manufacturers that “light” cigarettes were a healthier alternative to regular cigarettes. After learning that the marketing claims were false, she sued Altria and other cigarette manufacturers. She alleged that they had falsely marketed their “light” cigarettes as containing lower tar and nicotine in order to convey to consumers the impression that the cigarettes are less harmful than regular cigarettes. The class action lawsuit argued that in contrast, light cigarettes can actually be more harmful than regular cigarettes due to the cigarettes’ design. The lawsuit alleged that the companies had known this information and had deliberately deceived consumers systematically and over many years.
Plaintiffs specifically invoked the protections of the Maine Unfair Trade Practices Act (MUTPA), which prohibits unfair or deceptive acts or practices in commerce. The defendant cigarette companies argued that their cigarettes complied with federal cigarette safety warning laws and that the federal labeling law preempted the state consumer protection law.
Numerous similar lawsuits have been filed around the country and, faced with conflicting rulings from various courts, the U.S. Supreme Court agreed to take up the matter and resolve this preemption issue.
The ruling
The Supreme Court began with the assumption that the historic powers of states to regulate the health and welfare of their citizenry was not to be disturbed unless Congress specifically intended to do so. It then looked to the enactment of the federal Labeling Act of 1965 (which required cigarette manufacturers to include specific warnings about the potential hazards of smoking cigarettes) to determine whether Congress intended to preempt state labeling laws. Reviewing the many amendments and refinements enacted into law, the Court did find the intent to prohibit states from enacting stronger cigarette labeling laws – but only those laws that specifically addressed the labeling of cigarettes.
The Court was unable to find any support for the argument that state fraud laws were to be preempted. In fact, the court noted in a prior cigarette labeling case, unlike the concerns about wide divergence in labeling that led to Congress limiting state ability to mandate cigarette labels, fraud claims “rely only on a single, uniform standard: falsity.” Or, as AARP’s brief put it, “Make no mistake, this case is about fraud.” Since the MUTPA only addressed fraud and deceit as a general business practice, its general principles were not to be disturbed and defendants were not shielded by the federal cigarette labeling law.
In other words, the Court ruled that federal cigarette labeling law does not protect a manufacturer from liability for breaching the general duty not to lie to the public.
The ruling carries additional significance because the Court is considering this term another case that tests the balance between federal and state law. In Wyeth v. Levine, the pharmaceutical manufacturer is seeking to be shielded from liability because it complied with federal Food and Drug Administration approvals that did not require it to warn of specific dangers. In that case, Diana Levine went to the hospital suffering from migraines but had to later have her arm amputated after doctors intravenously administered a drug that destroyed her arteries. Levine alleged that the drug manufacturer had evidence that if the drug reached arteries, it could cause gangrene but despite this it did not warn of this danger. A jury agreed that the company had failed to warn of risks and awarded her $6.7 million in damages.
At trial and in its appeal, Wyeth argued that it was exempted from state tort law because the federal Food and Drug Administration (FDA) had approved the drug without requiring the warning sought and this preempted state tort law.
AARP’s briefs
In both Altria and Wyeth, the AARP “friend of the court” briefs filed by AARP Foundation Litigation attorneys pointed out that while regulatory agencies impose Congressionally-authorized requirements on manufacturers, those agencies face particular challenges. Both the Federal Trade Commission (which oversees cigarette labeling) and the Food and Drug Administration (pharmaceuticals) are chronically underfunded, often criticized for reliant relationships with industry, and have limited authority over the products -- with very little FTC oversight over cigarettes and extremely limited post-market oversight by the FDA.
Fortunately, there has been another safety net built into the legal system – the traditional tort lawsuit. By imposing the possibility of significant monetary penalties directly on wrongdoers, tort lawsuits incentivize those who develop, make, and distribute potentially dangerous products to do so with the utmost consideration for human health. The tort system plays a critical complementary role with agency regulatory processes to help ensure that items placed into the marketplace are as safe as possible and that any necessary warnings are adequately written and targeted.
The brief in Altria detailed the history of misrepresentation and deception in the marketing of “light” cigarettes, noting the voluminous evidence that has been presented indicating cigarette companies’ knowledge both that smokers were sensitive to health claims and that the health claims were exaggerated. One example of the sensitivity of “light” cigarette consumers: following aggressive health-based campaigns, the market share for “light” cigarettes skyrocketed from 2% in 1967 to 81% of cigarette sales in 1998.
Finally, AARP’s brief pointed out the absurdity of allowing the federal law to preempt state fraud law. Under a theory advanced by one of the defendants, the brief noted, cigarette manufacturers would be shielded from liability even if they made the following claims ”Smoking fights Parkinson’s Disease,” or “Smoking wards off depression.” As the brief put it, “Under Philip Morris’ reading, the Labeling Act – a statute designed to ensure that the public is informed of the risks of smoking – becomes an instrument of deception.”
AARP filed its brief in Altria with other health care and consumer protection advocates. The narrow 5-4 decision is a welcome ruling and could pave the way for further bolstering of state law remedies when the Court turns to Wyeth later this Term.
Contact persons:
Julie Nepveu
jnepveu@aarp.org
Stacy Canan
SCanan@aarp.org
Supreme Court Refuses to Allow Federal Labeling Law to Shield Against Fraud/Misrepresentation Claims
The U.S. Supreme Court ruled that manufacturers of potentially dangerous products are not shielded from state consumer law merely because their products have complied with federal labeling laws. The specific product at issue in Altria Group Inc. v. Good was “light” cigarettes, but the Court is also considering this term a case that asks whether federal law preempts state product liability claims against pharmaceutical manufacturers for labeling that fails to adequately warn of a drug’s risks.
AARP filed “friend of the court” briefs in both the cigarette and the pharmaceutical case, urging the Court not to preempt state laws because doing so would limit state efforts to protect the health and welfare of their citizens -- allowing consumers who have been injured as a result of a manufacturer’s deceptive practices or faulty manufacturing without a remedy for the harm.
The dispute
Stephanie Good was a smoker who lived in Maine and favored Marlboro Lights and Cambridge Lights cigarettes, believing the marketing claims by cigarette manufacturers that “light” cigarettes were a healthier alternative to regular cigarettes. After learning that the marketing claims were false, she sued Altria and other cigarette manufacturers. She alleged that they had falsely marketed their “light” cigarettes as containing lower tar and nicotine in order to convey to consumers the impression that the cigarettes are less harmful than regular cigarettes. The class action lawsuit argued that in contrast, light cigarettes can actually be more harmful than regular cigarettes due to the cigarettes’ design. The lawsuit alleged that the companies had known this information and had deliberately deceived consumers systematically and over many years.
Plaintiffs specifically invoked the protections of the Maine Unfair Trade Practices Act (MUTPA), which prohibits unfair or deceptive acts or practices in commerce. The defendant cigarette companies argued that their cigarettes complied with federal cigarette safety warning laws and that the federal labeling law preempted the state consumer protection law.
Numerous similar lawsuits have been filed around the country and, faced with conflicting rulings from various courts, the U.S. Supreme Court agreed to take up the matter and resolve this preemption issue.
The ruling
The Supreme Court began with the assumption that the historic powers of states to regulate the health and welfare of their citizenry was not to be disturbed unless Congress specifically intended to do so. It then looked to the enactment of the federal Labeling Act of 1965 (which required cigarette manufacturers to include specific warnings about the potential hazards of smoking cigarettes) to determine whether Congress intended to preempt state labeling laws. Reviewing the many amendments and refinements enacted into law, the Court did find the intent to prohibit states from enacting stronger cigarette labeling laws – but only those laws that specifically addressed the labeling of cigarettes.
The Court was unable to find any support for the argument that state fraud laws were to be preempted. In fact, the court noted in a prior cigarette labeling case, unlike the concerns about wide divergence in labeling that led to Congress limiting state ability to mandate cigarette labels, fraud claims “rely only on a single, uniform standard: falsity.” Or, as AARP’s brief put it, “Make no mistake, this case is about fraud.” Since the MUTPA only addressed fraud and deceit as a general business practice, its general principles were not to be disturbed and defendants were not shielded by the federal cigarette labeling law.
In other words, the Court ruled that federal cigarette labeling law does not protect a manufacturer from liability for breaching the general duty not to lie to the public.
The ruling carries additional significance because the Court is considering this term another case that tests the balance between federal and state law. In Wyeth v. Levine, the pharmaceutical manufacturer is seeking to be shielded from liability because it complied with federal Food and Drug Administration approvals that did not require it to warn of specific dangers. In that case, Diana Levine went to the hospital suffering from migraines but had to later have her arm amputated after doctors intravenously administered a drug that destroyed her arteries. Levine alleged that the drug manufacturer had evidence that if the drug reached arteries, it could cause gangrene but despite this it did not warn of this danger. A jury agreed that the company had failed to warn of risks and awarded her $6.7 million in damages.
At trial and in its appeal, Wyeth argued that it was exempted from state tort law because the federal Food and Drug Administration (FDA) had approved the drug without requiring the warning sought and this preempted state tort law.
AARP’s briefs
In both Altria and Wyeth, the AARP “friend of the court” briefs filed by AARP Foundation Litigation attorneys pointed out that while regulatory agencies impose Congressionally-authorized requirements on manufacturers, those agencies face particular challenges. Both the Federal Trade Commission (which oversees cigarette labeling) and the Food and Drug Administration (pharmaceuticals) are chronically underfunded, often criticized for reliant relationships with industry, and have limited authority over the products -- with very little FTC oversight over cigarettes and extremely limited post-market oversight by the FDA.
Fortunately, there has been another safety net built into the legal system – the traditional tort lawsuit. By imposing the possibility of significant monetary penalties directly on wrongdoers, tort lawsuits incentivize those who develop, make, and distribute potentially dangerous products to do so with the utmost consideration for human health. The tort system plays a critical complementary role with agency regulatory processes to help ensure that items placed into the marketplace are as safe as possible and that any necessary warnings are adequately written and targeted.
The brief in Altria detailed the history of misrepresentation and deception in the marketing of “light” cigarettes, noting the voluminous evidence that has been presented indicating cigarette companies’ knowledge both that smokers were sensitive to health claims and that the health claims were exaggerated. One example of the sensitivity of “light” cigarette consumers: following aggressive health-based campaigns, the market share for “light” cigarettes skyrocketed from 2% in 1967 to 81% of cigarette sales in 1998.
Finally, AARP’s brief pointed out the absurdity of allowing the federal law to preempt state fraud law. Under a theory advanced by one of the defendants, the brief noted, cigarette manufacturers would be shielded from liability even if they made the following claims ”Smoking fights Parkinson’s Disease,” or “Smoking wards off depression.” As the brief put it, “Under Philip Morris’ reading, the Labeling Act – a statute designed to ensure that the public is informed of the risks of smoking – becomes an instrument of deception.”
AARP filed its brief in Altria with other health care and consumer protection advocates. The narrow 5-4 decision is a welcome ruling and could pave the way for further bolstering of state law remedies when the Court turns to Wyeth later this Term.
Contact persons:
Julie Nepveu
jnepveu@aarp.org
Stacy Canan
SCanan@aarp.org
Miami physician and nurse were sentenced today to 30 years and seven years in prison,
Prison Sentence One of the Longest Ever Received by a Physician in a Medicare Fraud Case
WASHINGTON, Dec. 17 /PRNewswire-USNewswire/ -- A Miami physician and nurse were sentenced today to 30 years and seven years in prison, respectively, in connection with their roles in an $11 million HIV infusion fraud scheme, Acting Assistant Attorney General Matthew Friedrich of the Criminal Division and U.S. Attorney R. Alexander Acosta of the Southern District of Florida announced. The 30-year prison sentence is one of the longest terms ever given to a physician in a federal Medicare fraud case.
Ana Alvarez-Jacinto, 54, and Sandra Mateos, 44, were sentenced today in U.S. District Court for the Southern District of Florida by Chief District Judge Federico Moreno. In addition to their prison sentences, Judge Moreno ordered both Alvarez-Jacinto and Mateos to serve three years of supervised release following their prison term and to pay $8,289,286 in restitution to the Medicare program.
Alvarez-Jacinto and Mateos were found guilty by a Miami jury on Oct. 17, 2008, after a two-week trial on one count of conspiracy to defraud the United States, to submit false claims, and to pay healthcare kickbacks, and one count of conspiracy to commit health care fraud. Alvarez-Jacinto was also convicted of three counts of submitting false claims to the Medicare program.
Evidence at trial established that the defendants worked at Saint Jude Rehab Center, Inc. (St. Jude), a clinic that purported to specialize in treating AIDS patients. Evidence at trial established that St. Jude was operated and owned by Carlos and Luis Benitez, and managed by convicted co-conspirators Aisa Perera and Mariela Rodriguez.
According to evidence presented at trial, in a five-month period between June and November 2003, Alvarez-Jacinto, with the assistance of Mateos, ordered hundreds of medically unnecessary HIV infusion treatments at the clinic. Evidence established that HIV positive Medicare patients were brought to the clinic by Carlos and Luis Benitez for the purpose of receiving cash payments in exchange for allowing the clinic to bill for unnecessary treatments. Testimony revealed that Mateos and other co-conspirators paid the patients cash kickbacks of approximately $150 per visit. After patients had been paid, they agreed to allow Alvarez-Jacinto and her co-conspirators to prescribe unnecessary infusion treatments. St. Jude then billed Medicare for approximately $11 million for the unnecessary services during that five-month period. For those claims, Medicare paid more than $8 million to St. Jude.
"This is a case in which a physician provided unneeded medical services in the form of infusions to actual 'patients' simply to bilk Medicare and make a fast buck," said Acting Assistant Attorney General Matthew Friedrich. "This sentence should send a clear message that health care providers who engage in fraud will not escape accountability because of their professional status."
"False billings to Medicare for services not delivered is a serious crime that depletes our limited Medicare dollars. Far worse, however, is when medical professionals like the doctor and nurse sentenced today, actually order and perform medically unnecessary treatments to pad bills and make more money. Such conduct is inexcusable and will be prosecuted," said U.S. Attorney R. Alexander Acosta.
"Medical professionals are considered respected members of the community, but when that trust is broken, they are not insulated from having to take responsibility for their criminal behavior," said Special Agent in Charge Jonathan I. Solomon of the FBI's Miami Office. "This case demonstrates that those who choose to commit health care fraud, regardless of their stature or position, will be held accountable for their actions "The Office of Inspector General is very pleased with today's sentencing and will continue to aggressively investigate those who defraud the Medicare system. This type of greed, at the expense of our most vulnerable citizens will not be tolerated," said Christopher B. Dennis, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General - Miami region.
After trial, advertising placed in El Nuevo Herald proclaimed Alvarez-Jacinto's innocence and a letter signed by the defendant contained in the advertisement urged members of the medical community to write to the court to support her release from prison. At sentencing, Chief District Judge Moreno found her trial testimony to be perjurious and enhanced her sentence for obstruction of justice.
Carlos Benitez, Luis Benitez and Jose Benitez, were indicted on June 11, 2008, for their role in an HIV infusion and money laundering scheme that totaled more than $100 million for claims submitted by St. Jude and other clinics. The indictment alleges that Carlos, Luis and Jose Benitez were the masterminds of a large-scale HIV infusion fraud operation throughout South Florida involving at least 11 clinics, including St. Jude, and that they laundered the proceeds of their crimes. All three Benitez brothers remain at large.
An indictment is merely a charge, and defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt.
This case was prosecuted by Senior Trial Attorney Charles E. Duross, and Trial Attorneys John K. Neal and Laura Perkins of the Criminal Division's Fraud Section. The case was investigated by the FBI and the Department of Health and Human Services, Office of the Inspector General.
The case was brought by the Medicare Fraud Strike Force (MFSF). The MFSF is a multi-agency team of federal, state and local prosecutors and agents designed to combat Medicare fraud. Strike force operations began in the Miami-area on March 1, 2007. The MFSF is led by Deputy Chief Kirk Ogrosky of the Criminal Division's Fraud Section in Washington, D.C., and the office of U.S. Attorney R. Alexander Acosta of the Southern District of Florida. Since the inception of MFSF operations in 2007, federal prosecutors have indicted 106 cases with 188 defendants in both Los Angeles and Miami. Collectively, these defendants fraudulently billed the Medicare program for more than half a billion dollars.
SOURCE U.S. Department of Justice
Copyright©2008 PR Newswire.
All rights reserved
WASHINGTON, Dec. 17 /PRNewswire-USNewswire/ -- A Miami physician and nurse were sentenced today to 30 years and seven years in prison, respectively, in connection with their roles in an $11 million HIV infusion fraud scheme, Acting Assistant Attorney General Matthew Friedrich of the Criminal Division and U.S. Attorney R. Alexander Acosta of the Southern District of Florida announced. The 30-year prison sentence is one of the longest terms ever given to a physician in a federal Medicare fraud case.
Ana Alvarez-Jacinto, 54, and Sandra Mateos, 44, were sentenced today in U.S. District Court for the Southern District of Florida by Chief District Judge Federico Moreno. In addition to their prison sentences, Judge Moreno ordered both Alvarez-Jacinto and Mateos to serve three years of supervised release following their prison term and to pay $8,289,286 in restitution to the Medicare program.
Alvarez-Jacinto and Mateos were found guilty by a Miami jury on Oct. 17, 2008, after a two-week trial on one count of conspiracy to defraud the United States, to submit false claims, and to pay healthcare kickbacks, and one count of conspiracy to commit health care fraud. Alvarez-Jacinto was also convicted of three counts of submitting false claims to the Medicare program.
Evidence at trial established that the defendants worked at Saint Jude Rehab Center, Inc. (St. Jude), a clinic that purported to specialize in treating AIDS patients. Evidence at trial established that St. Jude was operated and owned by Carlos and Luis Benitez, and managed by convicted co-conspirators Aisa Perera and Mariela Rodriguez.
According to evidence presented at trial, in a five-month period between June and November 2003, Alvarez-Jacinto, with the assistance of Mateos, ordered hundreds of medically unnecessary HIV infusion treatments at the clinic. Evidence established that HIV positive Medicare patients were brought to the clinic by Carlos and Luis Benitez for the purpose of receiving cash payments in exchange for allowing the clinic to bill for unnecessary treatments. Testimony revealed that Mateos and other co-conspirators paid the patients cash kickbacks of approximately $150 per visit. After patients had been paid, they agreed to allow Alvarez-Jacinto and her co-conspirators to prescribe unnecessary infusion treatments. St. Jude then billed Medicare for approximately $11 million for the unnecessary services during that five-month period. For those claims, Medicare paid more than $8 million to St. Jude.
"This is a case in which a physician provided unneeded medical services in the form of infusions to actual 'patients' simply to bilk Medicare and make a fast buck," said Acting Assistant Attorney General Matthew Friedrich. "This sentence should send a clear message that health care providers who engage in fraud will not escape accountability because of their professional status."
"False billings to Medicare for services not delivered is a serious crime that depletes our limited Medicare dollars. Far worse, however, is when medical professionals like the doctor and nurse sentenced today, actually order and perform medically unnecessary treatments to pad bills and make more money. Such conduct is inexcusable and will be prosecuted," said U.S. Attorney R. Alexander Acosta.
"Medical professionals are considered respected members of the community, but when that trust is broken, they are not insulated from having to take responsibility for their criminal behavior," said Special Agent in Charge Jonathan I. Solomon of the FBI's Miami Office. "This case demonstrates that those who choose to commit health care fraud, regardless of their stature or position, will be held accountable for their actions "The Office of Inspector General is very pleased with today's sentencing and will continue to aggressively investigate those who defraud the Medicare system. This type of greed, at the expense of our most vulnerable citizens will not be tolerated," said Christopher B. Dennis, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General - Miami region.
After trial, advertising placed in El Nuevo Herald proclaimed Alvarez-Jacinto's innocence and a letter signed by the defendant contained in the advertisement urged members of the medical community to write to the court to support her release from prison. At sentencing, Chief District Judge Moreno found her trial testimony to be perjurious and enhanced her sentence for obstruction of justice.
Carlos Benitez, Luis Benitez and Jose Benitez, were indicted on June 11, 2008, for their role in an HIV infusion and money laundering scheme that totaled more than $100 million for claims submitted by St. Jude and other clinics. The indictment alleges that Carlos, Luis and Jose Benitez were the masterminds of a large-scale HIV infusion fraud operation throughout South Florida involving at least 11 clinics, including St. Jude, and that they laundered the proceeds of their crimes. All three Benitez brothers remain at large.
An indictment is merely a charge, and defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt.
This case was prosecuted by Senior Trial Attorney Charles E. Duross, and Trial Attorneys John K. Neal and Laura Perkins of the Criminal Division's Fraud Section. The case was investigated by the FBI and the Department of Health and Human Services, Office of the Inspector General.
The case was brought by the Medicare Fraud Strike Force (MFSF). The MFSF is a multi-agency team of federal, state and local prosecutors and agents designed to combat Medicare fraud. Strike force operations began in the Miami-area on March 1, 2007. The MFSF is led by Deputy Chief Kirk Ogrosky of the Criminal Division's Fraud Section in Washington, D.C., and the office of U.S. Attorney R. Alexander Acosta of the Southern District of Florida. Since the inception of MFSF operations in 2007, federal prosecutors have indicted 106 cases with 188 defendants in both Los Angeles and Miami. Collectively, these defendants fraudulently billed the Medicare program for more than half a billion dollars.
SOURCE U.S. Department of Justice
Copyright©2008 PR Newswire.
All rights reserved
Department of Health and Human Services had failed to guard some of their confidential information.
HHS Mistakenly Leaks Medicare Recipients' Private Information
By Elaine Grant on Wednesday, December 17, 2008.
This week, thousands of Medicare recipients got an unpleasant surprise when they learned that the Department of Health and Human Services had failed to guard some of their confidential information.
NHPR's Elaine Grant has the story.
Web resources:
New Hampshire Department of Health and Human Services
New Hampshire ServiceLink
New Hampshire Department of Justice
Consumer Affairs Identity Theft Toolkit
It’s open enrollment time for people who use Medicare drug prescription plans, or the so-called Medicare Part D.
Figuring out which drug plan is the best one -- can be confusing enough.
But now there’s an added problem for 93-hundred New Hampshire residents.
The state Department of Health and Human Services says a staffer mistakenly sent their private information to health care providers.
HHS Associate Commissioner Nancy Rollins says the employee sent a routine email about Part D prescription plans to 61 long-term care and home health organizations in the state.
Staffers at those companies use the information to help their clients choose the right Medicare prescription plans.
But, says Nancy Rollins, something went wrong.
Rollinsfacts.wav: Unfortunately the information was contained in an Excel spreadsheet, and it was attached to a workbook. The workbook had a tab and a document that contained information about the 9,300 individuals.
That information included names, addresses, social security numbers and the amount of people’s monthly Medicare Part D premiums.
Rollins stresses that it did not include medical or prescription information.
The department discovered the error on December fourth when a health care provider called them.
HHS immediately called the attorney general’s office, reported the incident and set about trying to remedy the problem.
Rollins1.wav: We contacted the 61 professional health care providers, that included independent case managers home health care providers and so forth and asked them to delete the information and to provide us confirmation that that had been done.
New Hampshire organizations that have had a data breach are required by law to notify the people involved.
On Monday, HHS sent thousands of letters informing people about the incident.
Those letters advise people on ways to avoid becoming a victim of identity theft.
Among those prescriptions: put a fraud alert or a credit freeze on your accounts.
A fraud alert is exactly what it sounds like – it alerts your credit card company to be on the lookout for strange or unlikely charges.
A credit freeze keeps people from checking your credit report, a necessary step when opening accounts or making loans.
It’s a more draconian measure – although it can deter criminals, it can also make it harder for people to open legitimate accounts or to borrow money.
Lauren Noether is a senior assistant attorney general in New Hampshire.
Noetherfreeze: If you know you’re not going to be borrowing any money, you put a freeze on it and that way if someone has your name and social security they’re not opening bank accounts in your name or taking out a mortgage in your name that you may later on be presumed to be liable for.
The Department of Health and Human Services has set up hotlines for concerned citizens.
By early afternoon on Wednesday, almost 300 people had called.
HHS Associate Commissioner Nancy Rollins says the department is still investigating the incident and determining what, if any, disciplinary actions it will take against the employee.She admits that the department did not have policies in place that could have prevented the problem.
Policy.wav: We are addressing the individual issue here, but also looking at if there are policy and protocol ramifications that we need to revisit.
Rollins says participants who did not receive a letter from the department, did not have their name and information leaked.
She adds that if you need help with fraud alerts or credit freezes, you can get assistance from one of 13 Service Link organizations around the state.
Service Links are agencies that counsel seniors and adults with disabilities about long term care.
For help, call the Department of Health and Human Services.
For NHPR News, I’m Elaine Grant
By Elaine Grant on Wednesday, December 17, 2008.
This week, thousands of Medicare recipients got an unpleasant surprise when they learned that the Department of Health and Human Services had failed to guard some of their confidential information.
NHPR's Elaine Grant has the story.
Web resources:
New Hampshire Department of Health and Human Services
New Hampshire ServiceLink
New Hampshire Department of Justice
Consumer Affairs Identity Theft Toolkit
It’s open enrollment time for people who use Medicare drug prescription plans, or the so-called Medicare Part D.
Figuring out which drug plan is the best one -- can be confusing enough.
But now there’s an added problem for 93-hundred New Hampshire residents.
The state Department of Health and Human Services says a staffer mistakenly sent their private information to health care providers.
HHS Associate Commissioner Nancy Rollins says the employee sent a routine email about Part D prescription plans to 61 long-term care and home health organizations in the state.
Staffers at those companies use the information to help their clients choose the right Medicare prescription plans.
But, says Nancy Rollins, something went wrong.
Rollinsfacts.wav: Unfortunately the information was contained in an Excel spreadsheet, and it was attached to a workbook. The workbook had a tab and a document that contained information about the 9,300 individuals.
That information included names, addresses, social security numbers and the amount of people’s monthly Medicare Part D premiums.
Rollins stresses that it did not include medical or prescription information.
The department discovered the error on December fourth when a health care provider called them.
HHS immediately called the attorney general’s office, reported the incident and set about trying to remedy the problem.
Rollins1.wav: We contacted the 61 professional health care providers, that included independent case managers home health care providers and so forth and asked them to delete the information and to provide us confirmation that that had been done.
New Hampshire organizations that have had a data breach are required by law to notify the people involved.
On Monday, HHS sent thousands of letters informing people about the incident.
Those letters advise people on ways to avoid becoming a victim of identity theft.
Among those prescriptions: put a fraud alert or a credit freeze on your accounts.
A fraud alert is exactly what it sounds like – it alerts your credit card company to be on the lookout for strange or unlikely charges.
A credit freeze keeps people from checking your credit report, a necessary step when opening accounts or making loans.
It’s a more draconian measure – although it can deter criminals, it can also make it harder for people to open legitimate accounts or to borrow money.
Lauren Noether is a senior assistant attorney general in New Hampshire.
Noetherfreeze: If you know you’re not going to be borrowing any money, you put a freeze on it and that way if someone has your name and social security they’re not opening bank accounts in your name or taking out a mortgage in your name that you may later on be presumed to be liable for.
The Department of Health and Human Services has set up hotlines for concerned citizens.
By early afternoon on Wednesday, almost 300 people had called.
HHS Associate Commissioner Nancy Rollins says the department is still investigating the incident and determining what, if any, disciplinary actions it will take against the employee.She admits that the department did not have policies in place that could have prevented the problem.
Policy.wav: We are addressing the individual issue here, but also looking at if there are policy and protocol ramifications that we need to revisit.
Rollins says participants who did not receive a letter from the department, did not have their name and information leaked.
She adds that if you need help with fraud alerts or credit freezes, you can get assistance from one of 13 Service Link organizations around the state.
Service Links are agencies that counsel seniors and adults with disabilities about long term care.
For help, call the Department of Health and Human Services.
For NHPR News, I’m Elaine Grant
Friday, December 5, 2008
Anti-fraud efforts snagged $1.1 billion in ’07...is this something to be proud of?
Anti-fraud efforts snagged $1.1 billion in ’07
Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.
Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.
Not sure if this is something to boast about!>?
What about the NCFE case in Ohio? National Century Finance Enterprises, Inc., the largest private fraud case in the history of this country!
In fiscal 2007. the agencies appropriated $166 million from the Medicare trust fund and recovered $1.1 billion
In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion
Posted: December 3, 2008 - 3:00 pm EDT
Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.The program, established by the Health Insurance Portability and Accountability Act of 1996, calls for the agencies to appropriate money from the Medicare trust fund to fight fraud perpetrated against federal health programs. Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.
The dollars returned to the federal treasury as a result included $201 million in criminal fines, $211 million in penalties and damages, and $186 million from disallowed payments identified and recovered through audits. In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion. Money collected on behalf of state Medicaid programs and private payers is not represented in the figures. (See the reports for 2007 and 2006.) -- by Gregg Blesch
http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20081203/REG/312039974/1024/rss01&rssfeed=rss01&nocache=1&nocache=1
Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.
Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.
Not sure if this is something to boast about!>?
What about the NCFE case in Ohio? National Century Finance Enterprises, Inc., the largest private fraud case in the history of this country!
In fiscal 2007. the agencies appropriated $166 million from the Medicare trust fund and recovered $1.1 billion
In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion
Posted: December 3, 2008 - 3:00 pm EDT
Fraud-busting efforts of the Justice Department and HHS brought in $1.1 billion in fiscal 2007 for the federal government and private whistle-blowers, according to the annual report of the Health Care Fraud and Abuse Control Program.The program, established by the Health Insurance Portability and Accountability Act of 1996, calls for the agencies to appropriate money from the Medicare trust fund to fight fraud perpetrated against federal health programs. Two-thirds of the $249 million allotted in 2007 went to the HHS’ inspector general’s office and accounts for the majority of its resources.
The dollars returned to the federal treasury as a result included $201 million in criminal fines, $211 million in penalties and damages, and $186 million from disallowed payments identified and recovered through audits. In fiscal 2006, the agencies appropriated $241 million from the Medicare trust fund and recovered $1.8 billion. Money collected on behalf of state Medicaid programs and private payers is not represented in the figures. (See the reports for 2007 and 2006.) -- by Gregg Blesch
http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20081203/REG/312039974/1024/rss01&rssfeed=rss01&nocache=1&nocache=1
Businessman Admits To Fraud With Motorized Wheelchairs
Edem James Etuk, 54, the owner of PMS Medical Equipment Distributors
Etuk admitted that as the owner of PMS, a durable medical equipment company, he participated in a conspiracy that resulted in fraudulent billing of Medicare of approximately $3.8 million.
Medicare paid approximately $1,627,000 to PMS over the course of the conspiracy.
As part of his agreement with the federal government, Etuk has agreed to pay $1,627,053 in restitution to Medicare and to cooperate with the government in its continuing investigation and prosecution of individuals committing fraud against the Medicare and Medicaid programs.
HOUSTON, TEXAS—Edem James Etuk, 54, the owner of PMS Medical Equipment Distributors has pleaded guilty to conspiring to defraud Medicare and health care fraud through a “motorized wheelchair scheme”.
At a hearing before U. S. District Judge Lynn N. Hughes, Etuk admitted that as the owner of PMS, a durable medical equipment company, he participated in a conspiracy that resulted in fraudulent billing of Medicare of approximately $3.8 million.
Prosecutors say that during the course of a 14-month period, Etuk and several individuals, including a Houston doctor presently under separate indictment and pending trial in April 2008, conspired to commit health care fraud, wire fraud and to illegally pay kick-backs in relation to the Medicare program. Etuk admitted he engaged in a scheme to defraud Medicare by billing Medicare for motorized wheelchairs which were either not required by the Medicare beneficiary or not delivered, or both.
Etuk purchased falsified Certificates of Medical Necessity (CMN), which are required to bill Medicare, for $200 each from several doctors. The Medicare beneficiaries in this case were recruited illegally by marketers. Etuk admitted paying Houston marketers for recruiting beneficiaries and even purchased CMNs directly from the marketers for $600 to $1000 each. The fraudulent CMNs were used by Etuk to falsely bill Medicare for approximately $3,880,000 in power wheelchairs and accessories. Medicare paid approximately $1,627,000 to PMS over the course of the conspiracy.
As part of his agreement with the federal government, Etuk has agreed to pay $1,627,053 in restitution to Medicare and to cooperate with the government in its continuing investigation and prosecution of individuals committing fraud against the Medicare and Medicaid programs.
The health care fraud count carries a maximum penalty of 10 years in a federal prison and a $250,000 fine. The conspiracy carries a penalty of five years imprisonment and a $250,000 fine. Parole has been abolished in the federal prison system. Sentencing has been scheduled for Jan. 14. 10-17-07
Etuk admitted that as the owner of PMS, a durable medical equipment company, he participated in a conspiracy that resulted in fraudulent billing of Medicare of approximately $3.8 million.
Medicare paid approximately $1,627,000 to PMS over the course of the conspiracy.
As part of his agreement with the federal government, Etuk has agreed to pay $1,627,053 in restitution to Medicare and to cooperate with the government in its continuing investigation and prosecution of individuals committing fraud against the Medicare and Medicaid programs.
HOUSTON, TEXAS—Edem James Etuk, 54, the owner of PMS Medical Equipment Distributors has pleaded guilty to conspiring to defraud Medicare and health care fraud through a “motorized wheelchair scheme”.
At a hearing before U. S. District Judge Lynn N. Hughes, Etuk admitted that as the owner of PMS, a durable medical equipment company, he participated in a conspiracy that resulted in fraudulent billing of Medicare of approximately $3.8 million.
Prosecutors say that during the course of a 14-month period, Etuk and several individuals, including a Houston doctor presently under separate indictment and pending trial in April 2008, conspired to commit health care fraud, wire fraud and to illegally pay kick-backs in relation to the Medicare program. Etuk admitted he engaged in a scheme to defraud Medicare by billing Medicare for motorized wheelchairs which were either not required by the Medicare beneficiary or not delivered, or both.
Etuk purchased falsified Certificates of Medical Necessity (CMN), which are required to bill Medicare, for $200 each from several doctors. The Medicare beneficiaries in this case were recruited illegally by marketers. Etuk admitted paying Houston marketers for recruiting beneficiaries and even purchased CMNs directly from the marketers for $600 to $1000 each. The fraudulent CMNs were used by Etuk to falsely bill Medicare for approximately $3,880,000 in power wheelchairs and accessories. Medicare paid approximately $1,627,000 to PMS over the course of the conspiracy.
As part of his agreement with the federal government, Etuk has agreed to pay $1,627,053 in restitution to Medicare and to cooperate with the government in its continuing investigation and prosecution of individuals committing fraud against the Medicare and Medicaid programs.
The health care fraud count carries a maximum penalty of 10 years in a federal prison and a $250,000 fine. The conspiracy carries a penalty of five years imprisonment and a $250,000 fine. Parole has been abolished in the federal prison system. Sentencing has been scheduled for Jan. 14. 10-17-07
Hospital admits accepted improper payments from federal health insurance programs for more than five years...and only has to pay 36 mil?
"We expect health-care providers to come forward when they discover issues that could rise to the level of fraud without waiting for us to catch up to them," Fitzgerald said in a statement announcing the settlement.
Hospital settles fraud case for $36M
December 1, 2008 at 11:16 PM | Comments (0)
Condell Medical Center in Libertyville will pay a $36 million settlement to government health programs after the hospital said it accepted improper payments from federal health insurance programs for more than five years, the U.S. attorney's office in Chicago said Monday.
The improper payments, which Condell executives brougto the attention of the U.S. attorney, were uncovered in the process of the medical center's due diligence with Advocate Health Care, which Monday finalized a deal to buy the 283-bed hospital in Lake County for $180 million.
The settlement resolves deals that included improper loans made to physicians, leases with doctor practices that were below fair market value and hospital payments to doctors who performed "patient services without required written agreements," the U.S. attorney's office said in a statement.
Such deals were in violation of federal laws that essentially prohibit hospital payments to doctors for patient referrals. If a hospital, for example, leases space to a physician at below fair market value, that can be construed as a way to encourage doctors to send patients to the hospital leasing the space.
The deals led to millions of improper payments to the hospital from the Medicare health insurance program for the elderly and the state Medicaid health insurance program for the poor. The settlement, which involves improper deals from 2002 through 2007, calls for Condell to pay the federal government $33.12 million to resolve claims related to Medicare and $2.88 million to resolve claims related to Medicaid.
As part of the settlement, the U.S. attorney's office said Condell "does not admit liability and agreed to the settlement to avoid the delay, uncertainty and expense of protracted litigation."
"We regret that in the past Condell may have been engaged in any practices that were not compliant with the law, and remain committed to the highest standards of conduct," said Dennis Millirons, Condell's chief executive officer.
By voluntarily disclosing the illegal relationships and contracts, "Condell avoided a government lawsuit under the federal False Claims Act and was able to negotiate a settlement at a discount," the U.S. attorney's office said. Such a lawsuit could have led to a settlement that would have cost Condell another $10 million or more, according to federal formulas used to calculate health care settlements.
Still, U.S. Atty. Patrick J. Fitzgerald praised Condell "for bringing these practices" to the government's attention.
"We expect health-care providers to come forward when they discover issues that could rise to the level of fraud without waiting for us to catch up to them," Fitzgerald said in a statement announcing the settlement.
--Bruce Japsen
http://www.chicagobreakingnews.com/2008/12/condell-fraud-settlement.html
Hospital settles fraud case for $36M
December 1, 2008 at 11:16 PM | Comments (0)
Condell Medical Center in Libertyville will pay a $36 million settlement to government health programs after the hospital said it accepted improper payments from federal health insurance programs for more than five years, the U.S. attorney's office in Chicago said Monday.
The improper payments, which Condell executives brougto the attention of the U.S. attorney, were uncovered in the process of the medical center's due diligence with Advocate Health Care, which Monday finalized a deal to buy the 283-bed hospital in Lake County for $180 million.
The settlement resolves deals that included improper loans made to physicians, leases with doctor practices that were below fair market value and hospital payments to doctors who performed "patient services without required written agreements," the U.S. attorney's office said in a statement.
Such deals were in violation of federal laws that essentially prohibit hospital payments to doctors for patient referrals. If a hospital, for example, leases space to a physician at below fair market value, that can be construed as a way to encourage doctors to send patients to the hospital leasing the space.
The deals led to millions of improper payments to the hospital from the Medicare health insurance program for the elderly and the state Medicaid health insurance program for the poor. The settlement, which involves improper deals from 2002 through 2007, calls for Condell to pay the federal government $33.12 million to resolve claims related to Medicare and $2.88 million to resolve claims related to Medicaid.
As part of the settlement, the U.S. attorney's office said Condell "does not admit liability and agreed to the settlement to avoid the delay, uncertainty and expense of protracted litigation."
"We regret that in the past Condell may have been engaged in any practices that were not compliant with the law, and remain committed to the highest standards of conduct," said Dennis Millirons, Condell's chief executive officer.
By voluntarily disclosing the illegal relationships and contracts, "Condell avoided a government lawsuit under the federal False Claims Act and was able to negotiate a settlement at a discount," the U.S. attorney's office said. Such a lawsuit could have led to a settlement that would have cost Condell another $10 million or more, according to federal formulas used to calculate health care settlements.
Still, U.S. Atty. Patrick J. Fitzgerald praised Condell "for bringing these practices" to the government's attention.
"We expect health-care providers to come forward when they discover issues that could rise to the level of fraud without waiting for us to catch up to them," Fitzgerald said in a statement announcing the settlement.
--Bruce Japsen
http://www.chicagobreakingnews.com/2008/12/condell-fraud-settlement.html
HHS and DOJ Health Care Fraud and Abuse Control Program
HHS and DOJ Health Care Fraud and Abuse Control Program
Annual Report For FY 2007
The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program
Annual Report For FY 2007,
November 2008
"The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS)1, acting through the Department’s Inspector General (HHS/OIG), designed to coordinate Federal, state and local law enforcement activities with respect to health care fraud and abuse. In its eleventh year of operation, the Program’s continued success again confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud or abuse, and to protect program beneficiaries."
Permanent Link Topic(s): E-Government, Government Documents
Annual Report For FY 2007
The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program
Annual Report For FY 2007,
November 2008
"The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS)1, acting through the Department’s Inspector General (HHS/OIG), designed to coordinate Federal, state and local law enforcement activities with respect to health care fraud and abuse. In its eleventh year of operation, the Program’s continued success again confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud or abuse, and to protect program beneficiaries."
Permanent Link Topic(s): E-Government, Government Documents
If only there were also programs like this in developed countries.
Monday, December 01, 2008
Two Important Resources Last month, I was fortunate to be able to attend the 13th International Anti-Corruption Conference in Athens, Greece, where I learned about two important additions to our resources relevant to the issues discussed on Health Care Renewal, specifically to improving integrity and transparency to the manufacture, promotion, and use of pharmaceuticals.
The Medicines Transparency AllianceFormed this year, this group seeks to bring "together at both the international and national levels, a diverse group of people with an interest in the pharmaceutical sector (stakeholders) to find ways to improve information flows, and increase transparency and accountability about the selection, regulation, procurement, sale, distribution and use of medicines in developing countries. By doing so, MeTA will improve how decisions are made about medicines, improve the way they are purchased and supplied, encourage innovative and responsible business practices, and increase the voice of patients and consumers." The Alliance will be focused mainly on developing countries, so that "when a country implements MeTA, it makes a commitment to progressively disclose a standard set of core data covering the quality, availability, price and promotion of medicines. This commitment also includes fully involving civil society, business and other stakeholders to work together to generate, disclose, debate and use these data to help address problems in the pharmaceutical market."
The Alliance has launched programs in Peru and Ghana, and plans to launch programs in Kyrgyzstan and Jordan.
The World Health Organization (WHO) Good Governance for Medicines Programme
This program has been in operation for several years, but seems to have a new and improved web-site. The site notes "Theft, extortion and abuse …the US$ 3 trillion-plus spent on health services worldwide each year are an obvious target for corruption. In fact, Transparency International estimates that 10 to 25 % of global public health procurement spending is siphoned off and stolen. Life-saving resources are being snatched away from the millions of people that need them most. The pharmaceutical sector, with its US$ 600 billion-plus global market value, is vulnerable to fraud." The goal of the programme "is to improve this situation. Guided by WHO’s Medicines Strategy 2004-2007 and launched in late 2004, the programme is raising awareness of abuse in the public pharmaceutical sector and promoting good governance. Its ultimate aim is to ensure that essential medicines reach people - not the black market."
If only there were also programs like this in developed countries.
Labels: Medicines Transparency Alliance, pharmaceuticals, WHO Good Governance for Medicines Programme
posted by Roy M. Poses MD at 11:42 AM
Links to this post
Two Important Resources Last month, I was fortunate to be able to attend the 13th International Anti-Corruption Conference in Athens, Greece, where I learned about two important additions to our resources relevant to the issues discussed on Health Care Renewal, specifically to improving integrity and transparency to the manufacture, promotion, and use of pharmaceuticals.
The Medicines Transparency AllianceFormed this year, this group seeks to bring "together at both the international and national levels, a diverse group of people with an interest in the pharmaceutical sector (stakeholders) to find ways to improve information flows, and increase transparency and accountability about the selection, regulation, procurement, sale, distribution and use of medicines in developing countries. By doing so, MeTA will improve how decisions are made about medicines, improve the way they are purchased and supplied, encourage innovative and responsible business practices, and increase the voice of patients and consumers." The Alliance will be focused mainly on developing countries, so that "when a country implements MeTA, it makes a commitment to progressively disclose a standard set of core data covering the quality, availability, price and promotion of medicines. This commitment also includes fully involving civil society, business and other stakeholders to work together to generate, disclose, debate and use these data to help address problems in the pharmaceutical market."
The Alliance has launched programs in Peru and Ghana, and plans to launch programs in Kyrgyzstan and Jordan.
The World Health Organization (WHO) Good Governance for Medicines Programme
This program has been in operation for several years, but seems to have a new and improved web-site. The site notes "Theft, extortion and abuse …the US$ 3 trillion-plus spent on health services worldwide each year are an obvious target for corruption. In fact, Transparency International estimates that 10 to 25 % of global public health procurement spending is siphoned off and stolen. Life-saving resources are being snatched away from the millions of people that need them most. The pharmaceutical sector, with its US$ 600 billion-plus global market value, is vulnerable to fraud." The goal of the programme "is to improve this situation. Guided by WHO’s Medicines Strategy 2004-2007 and launched in late 2004, the programme is raising awareness of abuse in the public pharmaceutical sector and promoting good governance. Its ultimate aim is to ensure that essential medicines reach people - not the black market."
If only there were also programs like this in developed countries.
Labels: Medicines Transparency Alliance, pharmaceuticals, WHO Good Governance for Medicines Programme
posted by Roy M. Poses MD at 11:42 AM
Links to this post
Court approves Medicare freeze on payments to Miami home healthcare companies
Medicare will continue to suspend payments to Miami home healthcare agencies suspected of fraud, according to a November 24 Miami Herald article.
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.
A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.
According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.
Miami Herald article.
By: Compliance Monitor
December 1st, 2008
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.
A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.
According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.
Miami Herald article.
By: Compliance Monitor
December 1st, 2008
Condell, the largest health care provider in Lake County, Ill., $36 Million Settlement After Self-Reporting Possible Health-Care Fraud
Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care Fraud
December 1, 2008
Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care FraudCondell Health Network, parent corporation of Condell Medical Center, a 283-bed hospital in Libertyville - after voluntarily disclosing that it received improper Medicare and Medicaid payments - has agreed without litigation to pay the United States and the State of Illinois$36 million as a result of filing false claims for reimbursement, announced Patrick J. Fitzgerald, U.S. Attorney for the Northern District of Illinois. Condell, the largest health care provider in Lake County, Ill., made the voluntary disclosure earlier this year while in the process of being acquired by Advocate Health Care, of Oak Brook, Ill., which was scheduled to be completed today. Full release
Posted by Admin at 02:56 PM
http://www.newsunfiltered.com/archives/2008/12/condell_health.html
December 1, 2008
Condell Health Network and Medical Center to Pay $36 Million Settlement After Self-Reporting Possible Health-Care FraudCondell Health Network, parent corporation of Condell Medical Center, a 283-bed hospital in Libertyville - after voluntarily disclosing that it received improper Medicare and Medicaid payments - has agreed without litigation to pay the United States and the State of Illinois$36 million as a result of filing false claims for reimbursement, announced Patrick J. Fitzgerald, U.S. Attorney for the Northern District of Illinois. Condell, the largest health care provider in Lake County, Ill., made the voluntary disclosure earlier this year while in the process of being acquired by Advocate Health Care, of Oak Brook, Ill., which was scheduled to be completed today. Full release
Posted by Admin at 02:56 PM
http://www.newsunfiltered.com/archives/2008/12/condell_health.html
Eight-count indictment for Fabian Aurignac ; health care fraud,...
McAllen Cardiologist Indicted For Health Care Fraud
Monday , December 01, 2008 Posted: 11:46 AM
Suspect faces up to 10 years in prison and fine of $250,000, if convicted
MCALLEN - A federal grand jury in McAllen has indicted cardiologist Fabian Aurignac for health care fraud, acting United States Attorney Tim Johnson announced today. Aurignac, formerly of McAllen, was arrested today in Austin, Texas, where he was to appear before the Texas Medical Board for a hearing regarding the suspension of his medical license. He is expected to make his initial appearance before a U.S. Magistrate Judge in Austin today at 3:00 p.m. The case will be prosecuted in McAllen.
The eight-count indictment, returned under seal Oct. 21, 2008, and unsealed today following his arrest, accuses Aurignac of defrauding the Medicaid and Medicare health care benefit programs by means of false and fraudulent claims in connection with the use of unlicensed, foreign doctors and medical personal and for billing for medical services not rendered. Aurignac, 45, faces a sentence of up to 10 years in prison and a maximum fine of $250,000, if convicted.
The investigation leading to the charges in this case was conducted by the FBI and the Texas Attorney General's Medicaid Fraud Control Unit. Assistant United States Attorney Carolyn Ferko is prosecuting the case. An Indictment is a formal accusation of criminal conduct, not evidence. The defendant is presumed innocent unless and until convicted through due process of law
Monday , December 01, 2008 Posted: 11:46 AM
Suspect faces up to 10 years in prison and fine of $250,000, if convicted
MCALLEN - A federal grand jury in McAllen has indicted cardiologist Fabian Aurignac for health care fraud, acting United States Attorney Tim Johnson announced today. Aurignac, formerly of McAllen, was arrested today in Austin, Texas, where he was to appear before the Texas Medical Board for a hearing regarding the suspension of his medical license. He is expected to make his initial appearance before a U.S. Magistrate Judge in Austin today at 3:00 p.m. The case will be prosecuted in McAllen.
The eight-count indictment, returned under seal Oct. 21, 2008, and unsealed today following his arrest, accuses Aurignac of defrauding the Medicaid and Medicare health care benefit programs by means of false and fraudulent claims in connection with the use of unlicensed, foreign doctors and medical personal and for billing for medical services not rendered. Aurignac, 45, faces a sentence of up to 10 years in prison and a maximum fine of $250,000, if convicted.
The investigation leading to the charges in this case was conducted by the FBI and the Texas Attorney General's Medicaid Fraud Control Unit. Assistant United States Attorney Carolyn Ferko is prosecuting the case. An Indictment is a formal accusation of criminal conduct, not evidence. The defendant is presumed innocent unless and until convicted through due process of law
Monday, December 1, 2008
Medicare by billing for $3.4 million in phony medical infusion services
Medicare by billing for $3.4 million in phony medical infusion services
$1.4 million from Medicare.Fraud Massachusetts
The Patriot Ledger, November 6, 2008
A federal grand jury indicted a Massachusetts man for allegedly scamming about $1.4 million from Medicare. Kingsley Tochukwu Eze, the owner and director of Kings Enterprize in Quincy, MA, was indicted on 14 counts of healthcare fraud, two counts of aggravated identity theft, and a single charge of making a false statement. Eze allegedly submitted false Medicare reimbursement claims for durable medical equipment in 2006 and 2007, according to the indictment.
A federal grand jury indicted a Massachusetts man for allegedly scamming about $1.4 million from Medicare. Kingsley Tochukwu Eze, the owner and director of Kings Enterprize in Quincy, MA, was indicted on 14 counts of healthcare fraud, two counts of aggravated identity theft, and a single charge of making a false statement. Eze allegedly submitted false Medicare reimbursement claims for durable medical equipment in 2006 and 2007, according to the indictment.
3 doctors sentenced to prison in health care fraud
ATLANTA (AP) An orthopedic surgeon and two chiropractors were sentenced Thursday to federal prison for cheating insurance companies out of $3 million by mislabeling treatments for back pain.
The sentences are the latest in Georgia to result from a back pain treatment known as Vertebral Axial Decompression.
The U.S. Attorney's Office said Dr. Howard Berkowitz, 58, of Atlanta was sentenced Thursday to 18 months, and the chiropractors, 67-year-old Arthur Hargraves of Douglasville, Ga., and 52-year-old Daniel Puffenberger of Kissimmee, Fla., each got three years and five months.
Berkowitz pleaded guilty and testified against his former partners in the Associated Spinal Care Network, which operated clinics in north Georgia and Tennessee. Prosecutors said the network faked reports to be reimbursed by Blue Cross/Blue Shield of Georgia for the Vax-D procedure, which was not covered by the insurance company.
VAX-D is a non-invasive treatment that uses a mechanical table to stretch a patient's spine. Blue Cross/Blue Shield of Georgia considered it investigational and not medically necessary, and made clear to health care providers that it did not cover the procedure.
The three men were convicted of using a different billing code that pertained to surgical nerve decompression, instead of the specific code assigned to VAX-D, to bill the company for more than $3 million from 2001 through 2005.
On Nov. 10, a federal jury in Atlanta convicted another chiropractor of a similar scheme. His two partners had already pleaded guilty. Another man pleaded guilty in 2005 to the same scheme at clinics in Albany and Columbus, Ga.
In the Northern District of Georgia, seven medical professionals have been convicted, and five were sentenced to a total of over 14 years in prison with monetary judgments topping $7 million.
The sentences are the latest in Georgia to result from a back pain treatment known as Vertebral Axial Decompression.
The U.S. Attorney's Office said Dr. Howard Berkowitz, 58, of Atlanta was sentenced Thursday to 18 months, and the chiropractors, 67-year-old Arthur Hargraves of Douglasville, Ga., and 52-year-old Daniel Puffenberger of Kissimmee, Fla., each got three years and five months.
Berkowitz pleaded guilty and testified against his former partners in the Associated Spinal Care Network, which operated clinics in north Georgia and Tennessee. Prosecutors said the network faked reports to be reimbursed by Blue Cross/Blue Shield of Georgia for the Vax-D procedure, which was not covered by the insurance company.
VAX-D is a non-invasive treatment that uses a mechanical table to stretch a patient's spine. Blue Cross/Blue Shield of Georgia considered it investigational and not medically necessary, and made clear to health care providers that it did not cover the procedure.
The three men were convicted of using a different billing code that pertained to surgical nerve decompression, instead of the specific code assigned to VAX-D, to bill the company for more than $3 million from 2001 through 2005.
On Nov. 10, a federal jury in Atlanta convicted another chiropractor of a similar scheme. His two partners had already pleaded guilty. Another man pleaded guilty in 2005 to the same scheme at clinics in Albany and Columbus, Ga.
In the Northern District of Georgia, seven medical professionals have been convicted, and five were sentenced to a total of over 14 years in prison with monetary judgments topping $7 million.
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