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

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

"...The CIA between Amerigroup and its subsidiary health plans " Who is the Subsidiary?

"...lawsuit against Amerigroup was originally filed by Cleveland Tyson, a former company employee."

"...avoided enrolling unhealthy patients.."

"...October 2006, a jury found Amerigroup liable..."

"...court entered a $334 million judgment against Amerigroup, which then filed an appeal with the U.S. Court of Appeals for the Seventh Circuit in Chicago seeking a reversal of the judgment. As part of the settlement, Amerigroup will dismiss its appeal and has agreed to enter into a Corporate Integrity Agreement (CIA) with the Office of Inspector General for the U.S. Department of Health and Human Services (HHS)."


OK!
My question is WHY is Amerigroup or ANY ONE OF ITS SUBSIDIARIES still allowed to conduct ANY BUSINESS in our Healthcare System?
"...CIA between Amerigroup and its subsidiary health plans and the Office of Inspector General requires the company to adopt policies and procedures, and a code of conduct designed to prevent improper discrimination against federal health care program beneficiaries in its marketing and enrollment practices. The CIA applies to Amerigroup's managed care plans in all the states – currently 11 – in which the company does business during the term of the agreement. In addition, Amerigroup must hire an independent organization to annually review its marketing practices and enrollment initiatives, and its board of directors must certify the effectiveness of its compliance program each year."

Thursday, August 14, 2008
Amerigroup Settles Federal & State Medicaid Fraud Claims for $225 Million WASHINGTON – Amerigroup Corporation has agreed to pay $225 million to resolve claims that it defrauded the Illinois Medicaid program, the Justice Department and the Attorney General of Illinois announced today. Amerigroup, which is headquartered in Virginia Beach, Va., operates managed health care plans throughout the United States.

Today’s settlement resolves allegations that Amerigroup and its Illinois subsidiary systematically avoided enrolling pregnant women, and unhealthy patients in their managed care program in Illinois. Amerigroup was paid by the United States and the state to operate a Medicaid managed care health plan in Illinois to provide health care to low income people. Amerigroup was required by law to enroll all eligible beneficiaries. The United States and the state of Illinois brought claims against the company alleging that it violated this requirement and avoided enrolling unhealthy patients, as well as pregnant women, who were more costly to treat and would have eroded Amerigroup’s profit margin.

In October 2006, a jury found Amerigroup liable under the federal False Claims Act and the Illinois Whistleblower Reward and Protection Act. The court entered a $334 million judgment against Amerigroup, which then filed an appeal with the U.S. Court of Appeals for the Seventh Circuit in Chicago seeking a reversal of the judgment. As part of the settlement, Amerigroup will dismiss its appeal and has agreed to enter into a Corporate Integrity Agreement (CIA) with the Office of Inspector General for the U.S. Department of Health and Human Services (HHS).
"The Justice Department is committed to ensuring that recipients of federal health care funds adhere to the law, so that appropriate health care services are provided to all eligible patients," said Gregory G. Katsas, Assistant Attorney General for the Civil Division.

"A settlement of this magnitude sends the clear message that this office takes health care fraud very seriously," said Patrick J. Fitzgerald, U.S. Attorney for the Northern District of Illinois. "This case also illustrates the perils a defendant faces in taking a case such as this to trial."

"This settlement should send a clear message that the state of Illinois will not tolerate illegal conduct in the provision of healthcare for Illinoisans," said Illinois Attorney General Lisa Madigan. "I am pleased that our work on this case will bring millions of dollars to the State of Illinois."

The CIA between Amerigroup and its subsidiary health plans and the Office of Inspector General requires the company to adopt policies and procedures, and a code of conduct designed to prevent improper discrimination against federal health care program beneficiaries in its marketing and enrollment practices. The CIA applies to Amerigroup's managed care plans in all the states – currently 11 – in which the company does business during the term of the agreement. In addition, Amerigroup must hire an independent organization to annually review its marketing practices and enrollment initiatives, and its board of directors must certify the effectiveness of its compliance program each year.
"The Office of Inspector General is committed to protecting Medicaid beneficiaries from fraud and discrimination" said HHS Inspector General Daniel R. Levinson. "This Corporate Integrity Agreement will help ensure that our most vulnerable beneficiaries have access to needed Medicaid HMO plans in the future."

The lawsuit against Amerigroup was originally filed by Cleveland Tyson, a former company employee. Under the federal False Claims Act and the Illinois Whistleblower Reward and Protection Act, a private party, known as a relator, is entitled to file suit alleging fraud on behalf of the federal or state government, respectively, and receive a share of any recovery. As a result of today’s recovery, Tyson will receive $56.25 million.

The case was handled by the U.S. Attorney’s Office for the Northern District of Illinois and the Illinois State Attorney General’s Office, with assistance from the Justice Department’s Civil Division and the Office of Inspector General for HHS, as well as by private counsel for the relator.

http://www.newyorkparalegalblog.com/2008/08/amerigroup-settles-federal-state.html

AIS's Report on Medicare Compliance (RMC) - Hospitals may be able to fend off recovery audit contractor ....

No wonder FRAUD is "OUT OF CONTROL"!!!


Many Hospital Claims Denials by Recovery Audit Contractors Are Overturned, as Process Itself Is Questioned
Hospitals may be able to fend off recovery audit contractor (RAC) claims denials for medically unnecessary admissions or services because some of them have been overturned, experts tell RMC.

Washington, DC (PRWEB) July 17, 2008 -- AIS's Report on Medicare Compliance (RMC) - Hospitals may be able to fend off recovery audit contractor (RAC) claims denials for medically unnecessary admissions or services because some of them have been overturned, experts tell RMC. If RACs are too quick to reject admissions because they don't meet screening criteria (e.g., InterQual) without looking at the entire medical record, hospitals may be able to reverse them. The best approach, however, is to have an effective up-front process that provides ample documentation of the decision making behind an inpatient admission as described in the Medicare Benefit Policy Manual. To read the full story, go to http://www.aishealth.com/Bnow/hbd070308.html.

Meanwhile, there's evidence that RACs may rush to judgment about some inpatient admissions, physician, Robert Corrato, M.D., CEO of Executive Health Resources tells RMC. For example, CMS appeals contractors and administrative law judges overturned more than 1,000 RAC claims denials appealed by hospitals in four states toward the end of the RAC pilot, which wrapped up in March, says Corrato, whose organization helped the hospitals mount appeals. The hospitals were able to prove that the admissions and/or services were medically necessary, he says.

However, CMS says that only 5% of RAC determinations were overturned on appeal from the beginning of the pilot through Oct. 31, 2007. "CMS does not expect this number to change significantly once the evaluation report of the three-year demonstration is released," a CMS official tells RMC. About 40% of the overpayments identified by RACs were based on their assertions that the services lacked medical necessity. But Corrato notes that "when the 5% figure was computed, very few cases had advanced to the third level of appeal (the ALJ)" and "CMS's own statistics...indicate that 44.2% of appealed cases were decided in favor of the provider."

This article has been excerpted from AIS's Report on Medicare Compliance (RMC). To access the story in its entirety, visit http://www.aishealth.com/Bnow/hbd070308.html.

About Report on Medicare Compliance

Published by Atlantic Information Services, Report on Medicare Compliance is written by veteran compliance editor and reporter, Nina Youngstrom. Since 1992, this award-winning weekly newsletter has been the industry's #1 source of compliance news and strategies ... on medical necessity, physician payments, DRG coding, quality of care, observation billing, Stark and more.