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
Showing posts with label Department of HHS. Show all posts
Showing posts with label Department of HHS. Show all posts
Friday, December 5, 2008
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
Tuesday, October 21, 2008
"MARTIN ACT" PROPOSED TO CRACK DOWN ON MEDICAID FRAUD
"Martin Act was used by the Attorney General with great success in prosecutions of fraud by investment banks, mutual funds and insurance companies. Those efforts led to the recovery of more than $6 billion for investors, businesses and the government. "
"MARTIN ACT" PROPOSED TO CRACK DOWN ON MEDICAID FRAUD
New Legislation Would Improve Prosecutors’ Ability to Fight Fraud
Attorney General Spitzer today proposed new Medicaid fraud legislation modeled after the statute he used to bring far-reaching reform to the financial industry.
Spitzer’s proposal, dubbed the "Martin Act for Health Care," removes limitations that hamper prosecution of health care fraud.
"New York State has been a national leader in the recovery of fraudulently obtained Medicaid funds," Spitzer said. "We could do even better if we strengthened the ability of prosecutors to prosecute obvious crimes."
In today’s health care delivery system, approaches to cheating the system by committing fraud have surpassed the dated definitions of larceny. This proposal overcomes the hypertechnical obstacles imposed by current law, and would allow prosecutors to bring cases against Medicaid providers who steal money through half-truths, omissions and deceptions.
The proposal would also help speed investigations and recoveries by providing new investigative tools for law enforcement authorities. For example, one key provision would allow the Attorney General to conduct examinations of Medicaid providers under oath and use the providers’ answers in civil recovery actions.
The Martin Act was used by the Attorney General with great success in prosecutions of fraud by investment banks, mutual funds and insurance companies. Those efforts led to the recovery of more than $6 billion for investors, businesses and the government.
Without Martin Act powers, New York still led the nation in Medicaid fraud recoveries, with $219 million recovered last year. With such powers, the Attorney General believes recoveries would increase significantly.
Spitzer previously introduced several bills aimed at improving Medicaid fraud recoveries and deterring fraud. One would provide financial incentives to those who report incidents of fraud and protects whistle blowers. Another would stiffen penalties for health care-related fraud.
The Attorney General maintains a toll-free tip-line for aid in his fight against Medicaid fraud. To report incidents of fraud or nursing home abuse contact: 866-NYS-FIGHT or (866-697-3444).
"MARTIN ACT" PROPOSED TO CRACK DOWN ON MEDICAID FRAUD
New Legislation Would Improve Prosecutors’ Ability to Fight Fraud
Attorney General Spitzer today proposed new Medicaid fraud legislation modeled after the statute he used to bring far-reaching reform to the financial industry.
Spitzer’s proposal, dubbed the "Martin Act for Health Care," removes limitations that hamper prosecution of health care fraud.
"New York State has been a national leader in the recovery of fraudulently obtained Medicaid funds," Spitzer said. "We could do even better if we strengthened the ability of prosecutors to prosecute obvious crimes."
In today’s health care delivery system, approaches to cheating the system by committing fraud have surpassed the dated definitions of larceny. This proposal overcomes the hypertechnical obstacles imposed by current law, and would allow prosecutors to bring cases against Medicaid providers who steal money through half-truths, omissions and deceptions.
The proposal would also help speed investigations and recoveries by providing new investigative tools for law enforcement authorities. For example, one key provision would allow the Attorney General to conduct examinations of Medicaid providers under oath and use the providers’ answers in civil recovery actions.
The Martin Act was used by the Attorney General with great success in prosecutions of fraud by investment banks, mutual funds and insurance companies. Those efforts led to the recovery of more than $6 billion for investors, businesses and the government.
Without Martin Act powers, New York still led the nation in Medicaid fraud recoveries, with $219 million recovered last year. With such powers, the Attorney General believes recoveries would increase significantly.
Spitzer previously introduced several bills aimed at improving Medicaid fraud recoveries and deterring fraud. One would provide financial incentives to those who report incidents of fraud and protects whistle blowers. Another would stiffen penalties for health care-related fraud.
The Attorney General maintains a toll-free tip-line for aid in his fight against Medicaid fraud. To report incidents of fraud or nursing home abuse contact: 866-NYS-FIGHT or (866-697-3444).
Wednesday, October 8, 2008
'Going door to door to sniff out fraud' We must!
Rampant Medicare fraud suspected in Miami
Miami may be ground zero,however this has been going on for years!
By Julie Appleby, USA TODAY
Home health care costs charged to Medicare in the Miami area have risen 20 times the national average in the past five years, prompting a federal investigation of suspected fraudulent billing.
Miami-Dade County is on track to cost Medicare a projected $1.3 billion for home health care services this fiscal year, up 1,300% in just five years, government data show.
SLEUTHS: Going door to door to sniff out fraud
Investigators suspect that fraud is helping to drive the increase because the population of Medicare beneficiaries in the county grew only 10.2% between 2004 and 2007, the latest government data show.
"You definitely have a problem down here," says Randall Culp, an FBI supervisory special agent who oversees a team that works with a Medicare Fraud Strike Force in Miami.
In South Florida, investigators say, some agencies are billing Medicare for millions of dollars in services that are unnecessary, overused or not provided at all.
Investigators elsewhere are paying attention because South Florida is a bellwether for scams that later surface in other large cities, such as Los Angeles and Houston. Scams involving fake AIDS treatments, for example, popped up in Detroit and several other cities after a crackdown in Miami, Culp and others say.
"Typically, Miami is ground zero. Then we see it move to the other high-fraud areas," says Suzanne Bradley, an investigator with the Centers for Medicare and Medicaid Service's field office in Miami.
Home health agencies send nurses and aides to assist homebound elderly and disabled beneficiaries. Nationally, Medicare expects to spend $16.5 billion on home health care this year, up 65% from five years ago.
Medicare spent six times more on home health care services in Miami-Dade County during the first five months of this year than in Los Angeles County, where the Medicare population is three times larger, agency data show.
"It jumps off the page as out of proportion," says Kirk Ogrosky, deputy chief in the Criminal Division's Fraud Section of the Justice Department.
Today, acting Medicare chief Kerry Weems says he will announce new anti-fraud efforts, some targeted at home care agencies in Miami.
"It does affect everyone because everyone is paying into Medicare," says Peggy Sposato, a nurse investigator with the U.S. attorney in the Southern District of Florida, who combs through data looking for unusual billings.
Miami may be ground zero,however this has been going on for years!
By Julie Appleby, USA TODAY
Home health care costs charged to Medicare in the Miami area have risen 20 times the national average in the past five years, prompting a federal investigation of suspected fraudulent billing.
Miami-Dade County is on track to cost Medicare a projected $1.3 billion for home health care services this fiscal year, up 1,300% in just five years, government data show.
SLEUTHS: Going door to door to sniff out fraud
Investigators suspect that fraud is helping to drive the increase because the population of Medicare beneficiaries in the county grew only 10.2% between 2004 and 2007, the latest government data show.
"You definitely have a problem down here," says Randall Culp, an FBI supervisory special agent who oversees a team that works with a Medicare Fraud Strike Force in Miami.
In South Florida, investigators say, some agencies are billing Medicare for millions of dollars in services that are unnecessary, overused or not provided at all.
Investigators elsewhere are paying attention because South Florida is a bellwether for scams that later surface in other large cities, such as Los Angeles and Houston. Scams involving fake AIDS treatments, for example, popped up in Detroit and several other cities after a crackdown in Miami, Culp and others say.
"Typically, Miami is ground zero. Then we see it move to the other high-fraud areas," says Suzanne Bradley, an investigator with the Centers for Medicare and Medicaid Service's field office in Miami.
Home health agencies send nurses and aides to assist homebound elderly and disabled beneficiaries. Nationally, Medicare expects to spend $16.5 billion on home health care this year, up 65% from five years ago.
Medicare spent six times more on home health care services in Miami-Dade County during the first five months of this year than in Los Angeles County, where the Medicare population is three times larger, agency data show.
"It jumps off the page as out of proportion," says Kirk Ogrosky, deputy chief in the Criminal Division's Fraud Section of the Justice Department.
Today, acting Medicare chief Kerry Weems says he will announce new anti-fraud efforts, some targeted at home care agencies in Miami.
"It does affect everyone because everyone is paying into Medicare," says Peggy Sposato, a nurse investigator with the U.S. attorney in the Southern District of Florida, who combs through data looking for unusual billings.
Tuesday, September 23, 2008
$15 M Medicaid fraud lawsuit dismissed against medical center
$15 M Medicaid fraud lawsuit dismissed against medical center
East Texas Medical Center Regional Healthcare System
9/22/2008 3:00 PM
By Michelle Massey, Texarkana Bureau
MARSHALL - A federal judge recently granted a summary judgment in a case alleging a health care system submitted false claims to Medicaid.
U. S. District Judge T. John Ward granted the motion for summary in late August, dismissing a lawsuit against East Texas Medical Center Regional Healthcare System.
The lawsuit alleged the company violated the False Claims Act by submitting claims to the federal government for over $15 million of federal Medicaid matching funds.
The lawsuit was filed under seal on June 8, 2005, but when the United States declined to intervene, the court unsealed the action on Feb. 6, 2007.
According to court records, East Texas Medical Center Regional Healthcare System is a hospital company that owns and operates private hospital facilities in East Texas, including co-defendant East Texas Medical Center Athens.
The suit filed against the defendants argues that the companies "devised and implemented a scheme to fraudulently receive additional Medicaid matching funds from the United States by illegally abusing the intergovernmental transfers procedure for the Medicaid Upper Payment Limits Program."
The program allows states to reimburse public rural hospitals for specific uncompensated care provided under Medicaid. The reimbursement is an amount equal to what Medicare would have paid for the same service.
Intergovernmental transfers -- transfers made from one government agency to another -- are used to partially fund the state's contribution to the upper payments limit program and then can be used to claim additional federal monies.
To participate in the program, federal regulations require states to separate the hospitals by facility type because public hospitals are eligible for a higher percentage of reimbursement than private non-profit hospitals.
There are three facility types: state government-owned or operated, non-state government-owned or operated,and privately owned and operated facilities.
The private, non-profit organization ETMC operates East Texas Medical Center Athens but the facility is owned by Henderson County and then leased to Henderson County Hospital Authority, who subleases it to ETMC.
In 2002, the entity selected by the state to develop the upper payments limit program, The Texas Organization of Rural and Community Hospitals (TORCH) advised East Texas Medical Center Athens that it qualified for the program and could receive significant additional funding.
The lawsuit asserts that East Texas Medical Center Athens is actually a private hospital and obtaining reimbursement at a higher percentage level is a false claim under the False Claims Act.
Specifically, the lawsuit alleges that the defendant "masqueraded" as a public hospital and then knowingly received the higher reimbursement.
The defendants argue that its lease agreement with the county makes its fall under the county-owned facility operated by a private company. Further, the defendants relied on TORCH's communication that it qualified under the program, although TORCH had a significant financial interest with their participation in the program.
Within Judge Ward's opinion, he failed to decide whether the defendant is a public hospital or whether the funds are prohibited.
Judge Ward emphasizes that a "private hospital is defined as 'owned and operated' privately, and a public hospital is 'owned or operated' by the government."
However, Judge Ward did find that the defendants did not knowingly make a false claim to the government.
Judge Ward wrote, that the defendants' "reliance on TORCH and its attorneys was reasonable. East Texas Medical Center Athens' failure to seek independent legal advice under these facts does not rise to the level of reckless disregard needed for a FCA claim. At most, it would constitute negligence, which is insufficient to assert a claim under the FCA."
With the August Order, Judge Ward grants the defendants' motion for summary judgment and dismisses the case.
Case No 2:05cv00216
East Texas Medical Center Regional Healthcare System
9/22/2008 3:00 PM
By Michelle Massey, Texarkana Bureau
MARSHALL - A federal judge recently granted a summary judgment in a case alleging a health care system submitted false claims to Medicaid.
U. S. District Judge T. John Ward granted the motion for summary in late August, dismissing a lawsuit against East Texas Medical Center Regional Healthcare System.
The lawsuit alleged the company violated the False Claims Act by submitting claims to the federal government for over $15 million of federal Medicaid matching funds.
The lawsuit was filed under seal on June 8, 2005, but when the United States declined to intervene, the court unsealed the action on Feb. 6, 2007.
According to court records, East Texas Medical Center Regional Healthcare System is a hospital company that owns and operates private hospital facilities in East Texas, including co-defendant East Texas Medical Center Athens.
The suit filed against the defendants argues that the companies "devised and implemented a scheme to fraudulently receive additional Medicaid matching funds from the United States by illegally abusing the intergovernmental transfers procedure for the Medicaid Upper Payment Limits Program."
The program allows states to reimburse public rural hospitals for specific uncompensated care provided under Medicaid. The reimbursement is an amount equal to what Medicare would have paid for the same service.
Intergovernmental transfers -- transfers made from one government agency to another -- are used to partially fund the state's contribution to the upper payments limit program and then can be used to claim additional federal monies.
To participate in the program, federal regulations require states to separate the hospitals by facility type because public hospitals are eligible for a higher percentage of reimbursement than private non-profit hospitals.
There are three facility types: state government-owned or operated, non-state government-owned or operated,and privately owned and operated facilities.
The private, non-profit organization ETMC operates East Texas Medical Center Athens but the facility is owned by Henderson County and then leased to Henderson County Hospital Authority, who subleases it to ETMC.
In 2002, the entity selected by the state to develop the upper payments limit program, The Texas Organization of Rural and Community Hospitals (TORCH) advised East Texas Medical Center Athens that it qualified for the program and could receive significant additional funding.
The lawsuit asserts that East Texas Medical Center Athens is actually a private hospital and obtaining reimbursement at a higher percentage level is a false claim under the False Claims Act.
Specifically, the lawsuit alleges that the defendant "masqueraded" as a public hospital and then knowingly received the higher reimbursement.
The defendants argue that its lease agreement with the county makes its fall under the county-owned facility operated by a private company. Further, the defendants relied on TORCH's communication that it qualified under the program, although TORCH had a significant financial interest with their participation in the program.
Within Judge Ward's opinion, he failed to decide whether the defendant is a public hospital or whether the funds are prohibited.
Judge Ward emphasizes that a "private hospital is defined as 'owned and operated' privately, and a public hospital is 'owned or operated' by the government."
However, Judge Ward did find that the defendants did not knowingly make a false claim to the government.
Judge Ward wrote, that the defendants' "reliance on TORCH and its attorneys was reasonable. East Texas Medical Center Athens' failure to seek independent legal advice under these facts does not rise to the level of reckless disregard needed for a FCA claim. At most, it would constitute negligence, which is insufficient to assert a claim under the FCA."
With the August Order, Judge Ward grants the defendants' motion for summary judgment and dismisses the case.
Case No 2:05cv00216
Thursday, August 21, 2008
Medicare instructed AdvanceMed to disregard those policies
"...officials at Medicare instructed AdvanceMed to disregard those policies...'
WOW! is this suppose to be a surprise?
What do you want from the Secretary of DHHS, who comes from the "FAMILY OWNED" LARGEST INSURANCE BROKER in the STATE of UTAH?
THE LEAVITT GROUPReport Rejects Medicare Boast of Paring Fraud
By CHARLES DUHIGG
Published: August 20, 2008
Medicare’s top officials said in 2006 that they had reduced the number of fraudulent and improper claims paid by the agency, keeping billions of dollars out of the hands of people trying to game the system.
But according to a confidential draft of a federal inspector general’s report, those claims of success, which earned Medicare wide praise from lawmakers, were misleading.
In calculating the agency’s rate of improper payments, Medicare officials told outside auditors to ignore government policies that would have accurately measured fraud, according to the report. For example, auditors were told not to compare invoices from salespeople against doctors’ records, as required by law, to make sure that medical equipment went to actual patients.
As a result, Medicare did not detect that more than one-third of spending for wheelchairs, oxygen supplies and other medical equipment in its 2006 fiscal year was improper, according to the report. Based on data in other Medicare reports, that would be about $2.8 billion in improper spending.
That same year, Medicare officials told Congress that they had succeeded in driving down the cost of fraud in medical equipment to $700 million.
Some lawmakers and Congressional staff members say the irregularities that the inspector general found were tantamount to corruption and raise broader questions about the credibility of other Medicare figures.
“This is outrageous,” said Senator Charles E. Grassley of Iowa, the top-ranking Republican on the Senate Finance Committee, who has repeatedly credited the Centers for Medicare and Medicaid Services with reducing improper expenditures. “If heads don’t roll, you can’t change the culture of this organization,” he added.
Senator Grassley had not yet received the full report from the inspector general but had been briefed on its contents.
The report — a draft of which was obtained by The New York Times — will probably be made public within the next week, according to federal officials. The inspector general may change or edit the findings of the report before it is officially released. Congressional staff said the Centers for Medicare and Medicaid Services — the agency overseeing Medicare — was lobbying the inspector to play down the report’s conclusions.
A spokesman for Medicare said that the agency agreed with the inspector general that the agency’s reported level of improper billing for durable medical equipment, or D.M.E., should have been higher. But Medicare says the $2.8 billion figure is unsupported.
“Allegations of manipulation of this error rate are preposterous,” said the spokesman, Jeff Nelligan. “The agency has aggressively targeted fraud and improper payments in the D.M.E. program. We have a history of working closely with the inspector general and will continue to do so.”
A representative of the Office of Inspector General that created the report — part of Medicare’s parent, the Department of Health and Human Services — said it did not comment on draft reports.
Fraudulent and improper payments have long bedeviled Medicare, a $466 billion program. In particular, payments for durable medical equipment, like power wheelchairs and diabetic test kits, are ripe for fraud.
Equipment sellers have submitted counterfeit documents, forged doctors’ signatures and filed claims on behalf of patients who were dead or had never been seen by the prescribing physician, according to many reports by government oversight agencies.
For example, a Florida businessman was sentenced last year to 37 months in prison for submitting more than $5.5 million of fake claims to Medicare. The businessman operated for months, despite giving the agency an address that was actually a utility closet.
On July 1, Medicare instituted a new competitive bidding system that officials said would reduce both fraud and costs for medical equipment.
On July 15, however, Congress suspended the program, after equipment manufacturers and sellers began an aggressive lobbying campaign.
Senator Grassley said Congress might push for an investigation into the private company that was hired to fulfill Medicare’s auditing program, the AdvanceMed Corporation, a division of the Computer Sciences Corporation. The report mentions AdvanceMed by name.
Representatives of AdvanceMed did not return calls. The company has received contracts worth more than $34 million from the Centers for Medicare and Medicaid Services since 2005.
“This report doesn’t surprise me,” said Representative Pete Stark, Democrat of California and a senior member of the Ways and Means Committee. He has pushed to cut improper Medicare spending. “To look better to the public, you cook the books,” he said. “This agency is incompetent.”
The Office of Inspector General’s report details scrutiny of a program known as Comprehensive Error Rate Testing, or CERT, that audits a sample of Medicare claims submitted by sellers of durable medical equipment. That program is supposed to randomly choose claims and review the medical records and other documents supporting submitted claims to determine whether payment is justified.
According to the inspector general’s report, officials at Medicare instructed AdvanceMed to disregard those policies. Instead, AdvanceMed was told to examine only the documents submitted by the companies selling the medical equipment, rather than verify those documents against physicians’ records.
Medicare reported to Congress that, for the fiscal year of 2006, AdvanceMed’s investigations had found that only 7.5 percent of claims paid by Medicare were not supported by appropriate documentation. But the inspector general’s review indicated that the actual error rate was closer to 31.5 percent.
For instance, according to the report, the Office of Inspector General examined a claim for an electric wheelchair that AdvanceMed had said was appropriate. The inspector general’s investigation revealed that the physician who was listed as having prescribed the wheelchair had no knowledge of the prescription.
The person who received the wheelchair said that he had never met with the physician, that he did not need a wheelchair and that he had never used it, according to the report. His wife had also received a wheelchair that she had not asked for and never used.
Equipment sellers can pocket more than $2,500 every time they send a powered wheelchair to a patient and bill Medicare.
“This is like letting the fox guard the henhouse,” said Malcolm Sparrow, a Harvard University professor who focuses on health care fraud. “The supplier has an incentive to supply fabricated documents or to imply that medical records support a purchase when they don’t. If you don’t ask the physician or ask for medical records, you can’t really verify anything.”
WOW! is this suppose to be a surprise?
What do you want from the Secretary of DHHS, who comes from the "FAMILY OWNED" LARGEST INSURANCE BROKER in the STATE of UTAH?
THE LEAVITT GROUPReport Rejects Medicare Boast of Paring Fraud
By CHARLES DUHIGG
Published: August 20, 2008
Medicare’s top officials said in 2006 that they had reduced the number of fraudulent and improper claims paid by the agency, keeping billions of dollars out of the hands of people trying to game the system.
But according to a confidential draft of a federal inspector general’s report, those claims of success, which earned Medicare wide praise from lawmakers, were misleading.
In calculating the agency’s rate of improper payments, Medicare officials told outside auditors to ignore government policies that would have accurately measured fraud, according to the report. For example, auditors were told not to compare invoices from salespeople against doctors’ records, as required by law, to make sure that medical equipment went to actual patients.
As a result, Medicare did not detect that more than one-third of spending for wheelchairs, oxygen supplies and other medical equipment in its 2006 fiscal year was improper, according to the report. Based on data in other Medicare reports, that would be about $2.8 billion in improper spending.
That same year, Medicare officials told Congress that they had succeeded in driving down the cost of fraud in medical equipment to $700 million.
Some lawmakers and Congressional staff members say the irregularities that the inspector general found were tantamount to corruption and raise broader questions about the credibility of other Medicare figures.
“This is outrageous,” said Senator Charles E. Grassley of Iowa, the top-ranking Republican on the Senate Finance Committee, who has repeatedly credited the Centers for Medicare and Medicaid Services with reducing improper expenditures. “If heads don’t roll, you can’t change the culture of this organization,” he added.
Senator Grassley had not yet received the full report from the inspector general but had been briefed on its contents.
The report — a draft of which was obtained by The New York Times — will probably be made public within the next week, according to federal officials. The inspector general may change or edit the findings of the report before it is officially released. Congressional staff said the Centers for Medicare and Medicaid Services — the agency overseeing Medicare — was lobbying the inspector to play down the report’s conclusions.
A spokesman for Medicare said that the agency agreed with the inspector general that the agency’s reported level of improper billing for durable medical equipment, or D.M.E., should have been higher. But Medicare says the $2.8 billion figure is unsupported.
“Allegations of manipulation of this error rate are preposterous,” said the spokesman, Jeff Nelligan. “The agency has aggressively targeted fraud and improper payments in the D.M.E. program. We have a history of working closely with the inspector general and will continue to do so.”
A representative of the Office of Inspector General that created the report — part of Medicare’s parent, the Department of Health and Human Services — said it did not comment on draft reports.
Fraudulent and improper payments have long bedeviled Medicare, a $466 billion program. In particular, payments for durable medical equipment, like power wheelchairs and diabetic test kits, are ripe for fraud.
Equipment sellers have submitted counterfeit documents, forged doctors’ signatures and filed claims on behalf of patients who were dead or had never been seen by the prescribing physician, according to many reports by government oversight agencies.
For example, a Florida businessman was sentenced last year to 37 months in prison for submitting more than $5.5 million of fake claims to Medicare. The businessman operated for months, despite giving the agency an address that was actually a utility closet.
On July 1, Medicare instituted a new competitive bidding system that officials said would reduce both fraud and costs for medical equipment.
On July 15, however, Congress suspended the program, after equipment manufacturers and sellers began an aggressive lobbying campaign.
Senator Grassley said Congress might push for an investigation into the private company that was hired to fulfill Medicare’s auditing program, the AdvanceMed Corporation, a division of the Computer Sciences Corporation. The report mentions AdvanceMed by name.
Representatives of AdvanceMed did not return calls. The company has received contracts worth more than $34 million from the Centers for Medicare and Medicaid Services since 2005.
“This report doesn’t surprise me,” said Representative Pete Stark, Democrat of California and a senior member of the Ways and Means Committee. He has pushed to cut improper Medicare spending. “To look better to the public, you cook the books,” he said. “This agency is incompetent.”
The Office of Inspector General’s report details scrutiny of a program known as Comprehensive Error Rate Testing, or CERT, that audits a sample of Medicare claims submitted by sellers of durable medical equipment. That program is supposed to randomly choose claims and review the medical records and other documents supporting submitted claims to determine whether payment is justified.
According to the inspector general’s report, officials at Medicare instructed AdvanceMed to disregard those policies. Instead, AdvanceMed was told to examine only the documents submitted by the companies selling the medical equipment, rather than verify those documents against physicians’ records.
Medicare reported to Congress that, for the fiscal year of 2006, AdvanceMed’s investigations had found that only 7.5 percent of claims paid by Medicare were not supported by appropriate documentation. But the inspector general’s review indicated that the actual error rate was closer to 31.5 percent.
For instance, according to the report, the Office of Inspector General examined a claim for an electric wheelchair that AdvanceMed had said was appropriate. The inspector general’s investigation revealed that the physician who was listed as having prescribed the wheelchair had no knowledge of the prescription.
The person who received the wheelchair said that he had never met with the physician, that he did not need a wheelchair and that he had never used it, according to the report. His wife had also received a wheelchair that she had not asked for and never used.
Equipment sellers can pocket more than $2,500 every time they send a powered wheelchair to a patient and bill Medicare.
“This is like letting the fox guard the henhouse,” said Malcolm Sparrow, a Harvard University professor who focuses on health care fraud. “The supplier has an incentive to supply fabricated documents or to imply that medical records support a purchase when they don’t. If you don’t ask the physician or ask for medical records, you can’t really verify anything.”
Friday, August 15, 2008
"...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
"...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
Thursday, August 7, 2008
The 21-count indictment, which was unsealed Wednesday, charged them with conspiring to receive and take kickbacks for patient referrals and to commit
FBI Raids Hospitals, Arrests CEO
Previous posts on Health Care Renewal have featured a rogues gallery of disgraced leaders of health care organizations. For example, we recently discussed a former hospital CEO who concealed that he had served time in the US Navy's brig. The Los Angeles Times just reported a story that suggests a new low in hospital leadership,
FBI agents served search warrants this morning on three hospitals as part of an investigation into alleged Medicare fraud involving homeless patients who were recruited from skid row.
Dr. Rudra Sabaratnam, an owner and the chief executive of City of Angels Medical Center, and Estill Mitts, an alleged patient recruiter, were indicted by a federal grand jury last week on 21 counts of healthcare fraud, money laundering and income tax evasion.
The men were arrested this morning as part of the federal government's criminal investigation, according to FBI spokeswoman Laura Eimiller.
''It's a scheme that ranged from street operatives to the CEO of a hospital,' said U.S. Atty. Thomas P. O'Brien, adding that he expects several more arrests in coming weeks.
At the same time, Los Angeles City Atty. Rocky Delgadillo announced civil litigation against the three hospitals and their operators in what officials said was a 'scheme to defraud the Medi-Cal and Medicare programs out of millions of dollars.'
Beginning at 8 a.m., agents working with the federal Department of Health and Human Services, the Internal Revenue Service and the California Department of Justice raided City of Angels Medical Center, Los Angeles Metropolitan Medical Center and Tustin Hospital and Medical Center.
The raids cap what law enforcement sources told The Times was a nearly two-year investigation of alleged medical fraud on skid row.
The city attorney's office alleged that the hospitals tried to fill empty beds in a bid to boost their finances.
The hospitals allegedly were aided by a patient recruiting operation on skid row that plucked homeless people from the streets and delivered them with fake medical conditions to the hospitals.
Metropolitan Medical Center in 2006 was accused by the Los Angeles Police Department of using ambulances to 'dump' five patients in one day onto the streets of the downtown skid row area against their will after their discharge from the hospital. At the time, officials at the hospital strongly denied any wrongdoing.
But the city attorney now alleges that those patients had been recruited 'by runners' who directed them to an assessment center on 7th Street, where their Medicare and Medi-Cal benefits eligibility was checked and a 'fabricated description of conditions' was prepared by non-doctors so they could be eligible for treatment. All five of the patients were admitted to Metropolitan Medical Center.
Each of the patients received $20 to $30 when they returned to the assessment center after spending one to three days in the hospital, according to the suit.
'Within the past four years, hundreds, if not thousands of other homeless persons in skid row have been recruited, hospitalized, treated and discharged in a manner substantially similar . . . as part of a long-running scheme to bilk the Medicare and Medi-Cal programs out of millions of dollars by causing unnecessary hospitalization for paid recruits,' the lawsuit alleges.
The list of the accused is striking.
Among those named in the suit are Pacific Health Care Corp.; Los Angeles Metropolitan Medical Center, its Chief Executive John Fenton and admitting physician Frederick Rundall; Tustin Hospital and Medical Center, its Chief Executive Daniel Davis, Chief Financial Officer Vincent Rubio and admitting physicians Kenneth Thaler and Al-Reza Tajik; and City of Angels Medical Center and its owner-operators Robert Borseau and Sabaratnam. Mitts, the owner and manager of Metropolitan Healthcare LLC and the president of the 7th Street Christian Day Center, which was until recently located on skid row, is also named in the suit.
City attorneys allege that the Tustin hospital was guaranteed 40 to 50 patients a month while City of Angels got 25 to 30 patients month. Metropolitan Medical Center received patients whenever beds were available, according to the suit. City attorneys allege the admitting Drs. Rundall, Thaler and Tajik did not see their patients until shortly before their discharge. City attorneys allege that for patient referrals, Mitts' group was paid $20,000 per month each from Metropolitan Medical Center and Tustin, while City of Angels paid between $400 to $1,000 a week to the recruiting group.
The suit also alleges that the Tustin hospital's chief financial officer personally received a $3,500-a-month kickback from Mitts' group to ensure that Tustin continued to take homeless patients from the skid row center.
The Associated Press (here, via the San Diego Union-Tribune) reported that two people, including one hospital CEO, were arrested during the raids.
FBI agents arrested Rudra Sabaratnam, 64, chief executive officer of City of Angels hospital, and Estill Mitts, 64, who operated the 7th Street Assessment Center, where people are screened for health needs, the U.S. attorney's office said in a statement.A federal jury last week indicted both men. The 21-count indictment, which was unsealed Wednesday, charged them with conspiring to receive and take kickbacks for patient referrals and to commit health care fraud.
Sabaratnam also was charged with paying kickbacks while Mitts also was charged with money laundering and tax evasion.
If convicted, Sabaratnam could face 50 years in federal prison, and Mitts could face 140 years, authorities said.
We have often discussed how health care has come to be dominated more and more by ever larger organizations. Thus, the leadership of these organizations has increasing influence over health care, and hence on people's health and safety. Yet on this blog we have documented more and ever sleazier examples of ill-informed, incompetent, self-interested, and even corrupt leadership of health care organizations.
The story above is of allegations, indictments, and lawsuits. But if half of the allegations in it are true, it would represent a new low for hospital leadership.
Thus, I raise again a proposal for licensure of leaders of all organizations that affect health care, starting with hospitals, academic medical centers, and hospital systems; but also including managed care organizations and health care insurers; drug, biotechnology, and device companies; health information technology companies; etc, etc, etc. Such licensure could assure that leaders have some minimum level of knowledge about and exposure to health care; and that they must conform to some ethical standards. Licensure could be subject to removal under due process. Clearly, licensing health care organizational leaders would not solve all or most of health care's problems. But it would at least assure some minimum standard of leadership.
http://hcrenewal.blogspot.com/2008/08/fbi-raids-hospitals-arrests-ceo.html
Previous posts on Health Care Renewal have featured a rogues gallery of disgraced leaders of health care organizations. For example, we recently discussed a former hospital CEO who concealed that he had served time in the US Navy's brig. The Los Angeles Times just reported a story that suggests a new low in hospital leadership,
FBI agents served search warrants this morning on three hospitals as part of an investigation into alleged Medicare fraud involving homeless patients who were recruited from skid row.
Dr. Rudra Sabaratnam, an owner and the chief executive of City of Angels Medical Center, and Estill Mitts, an alleged patient recruiter, were indicted by a federal grand jury last week on 21 counts of healthcare fraud, money laundering and income tax evasion.
The men were arrested this morning as part of the federal government's criminal investigation, according to FBI spokeswoman Laura Eimiller.
''It's a scheme that ranged from street operatives to the CEO of a hospital,' said U.S. Atty. Thomas P. O'Brien, adding that he expects several more arrests in coming weeks.
At the same time, Los Angeles City Atty. Rocky Delgadillo announced civil litigation against the three hospitals and their operators in what officials said was a 'scheme to defraud the Medi-Cal and Medicare programs out of millions of dollars.'
Beginning at 8 a.m., agents working with the federal Department of Health and Human Services, the Internal Revenue Service and the California Department of Justice raided City of Angels Medical Center, Los Angeles Metropolitan Medical Center and Tustin Hospital and Medical Center.
The raids cap what law enforcement sources told The Times was a nearly two-year investigation of alleged medical fraud on skid row.
The city attorney's office alleged that the hospitals tried to fill empty beds in a bid to boost their finances.
The hospitals allegedly were aided by a patient recruiting operation on skid row that plucked homeless people from the streets and delivered them with fake medical conditions to the hospitals.
Metropolitan Medical Center in 2006 was accused by the Los Angeles Police Department of using ambulances to 'dump' five patients in one day onto the streets of the downtown skid row area against their will after their discharge from the hospital. At the time, officials at the hospital strongly denied any wrongdoing.
But the city attorney now alleges that those patients had been recruited 'by runners' who directed them to an assessment center on 7th Street, where their Medicare and Medi-Cal benefits eligibility was checked and a 'fabricated description of conditions' was prepared by non-doctors so they could be eligible for treatment. All five of the patients were admitted to Metropolitan Medical Center.
Each of the patients received $20 to $30 when they returned to the assessment center after spending one to three days in the hospital, according to the suit.
'Within the past four years, hundreds, if not thousands of other homeless persons in skid row have been recruited, hospitalized, treated and discharged in a manner substantially similar . . . as part of a long-running scheme to bilk the Medicare and Medi-Cal programs out of millions of dollars by causing unnecessary hospitalization for paid recruits,' the lawsuit alleges.
The list of the accused is striking.
Among those named in the suit are Pacific Health Care Corp.; Los Angeles Metropolitan Medical Center, its Chief Executive John Fenton and admitting physician Frederick Rundall; Tustin Hospital and Medical Center, its Chief Executive Daniel Davis, Chief Financial Officer Vincent Rubio and admitting physicians Kenneth Thaler and Al-Reza Tajik; and City of Angels Medical Center and its owner-operators Robert Borseau and Sabaratnam. Mitts, the owner and manager of Metropolitan Healthcare LLC and the president of the 7th Street Christian Day Center, which was until recently located on skid row, is also named in the suit.
City attorneys allege that the Tustin hospital was guaranteed 40 to 50 patients a month while City of Angels got 25 to 30 patients month. Metropolitan Medical Center received patients whenever beds were available, according to the suit. City attorneys allege the admitting Drs. Rundall, Thaler and Tajik did not see their patients until shortly before their discharge. City attorneys allege that for patient referrals, Mitts' group was paid $20,000 per month each from Metropolitan Medical Center and Tustin, while City of Angels paid between $400 to $1,000 a week to the recruiting group.
The suit also alleges that the Tustin hospital's chief financial officer personally received a $3,500-a-month kickback from Mitts' group to ensure that Tustin continued to take homeless patients from the skid row center.
The Associated Press (here, via the San Diego Union-Tribune) reported that two people, including one hospital CEO, were arrested during the raids.
FBI agents arrested Rudra Sabaratnam, 64, chief executive officer of City of Angels hospital, and Estill Mitts, 64, who operated the 7th Street Assessment Center, where people are screened for health needs, the U.S. attorney's office said in a statement.A federal jury last week indicted both men. The 21-count indictment, which was unsealed Wednesday, charged them with conspiring to receive and take kickbacks for patient referrals and to commit health care fraud.
Sabaratnam also was charged with paying kickbacks while Mitts also was charged with money laundering and tax evasion.
If convicted, Sabaratnam could face 50 years in federal prison, and Mitts could face 140 years, authorities said.
We have often discussed how health care has come to be dominated more and more by ever larger organizations. Thus, the leadership of these organizations has increasing influence over health care, and hence on people's health and safety. Yet on this blog we have documented more and ever sleazier examples of ill-informed, incompetent, self-interested, and even corrupt leadership of health care organizations.
The story above is of allegations, indictments, and lawsuits. But if half of the allegations in it are true, it would represent a new low for hospital leadership.
Thus, I raise again a proposal for licensure of leaders of all organizations that affect health care, starting with hospitals, academic medical centers, and hospital systems; but also including managed care organizations and health care insurers; drug, biotechnology, and device companies; health information technology companies; etc, etc, etc. Such licensure could assure that leaders have some minimum level of knowledge about and exposure to health care; and that they must conform to some ethical standards. Licensure could be subject to removal under due process. Clearly, licensing health care organizational leaders would not solve all or most of health care's problems. But it would at least assure some minimum standard of leadership.
http://hcrenewal.blogspot.com/2008/08/fbi-raids-hospitals-arrests-ceo.html
Saturday, July 26, 2008
America’s Health Insurance Plans , Patient Privacy Rights said the revised bill is being reviewed and declined comment ....
House Energy and Commerce Committee Chair John Dingell (D-Mich.) and ranking member Joe Barton (R-Texas) on Tuesday released a revised version of a bill (HR 6357) that aims to promote nationwide adoption of an electronic health record system, CongressDaily reports. According to CongressDaily, the lawmakers “substantially changed the information-sharing and privacy provisions of their proposal” following “concerns from stakeholders in the health care, high-tech and consumer advocacy arenas.” The bill is scheduled for a full committee mark up on Wednesday (Noyes, CongressDaily, 7/22).
Under the revised bill, patients would give their consent only once to health care companies that want to access health care records without identifying information for HHS-approved purposes, such as hospital audits or fraud and abuse allegations. The bill previously would have required patient consent each time the records were accessed (Young, The Hill, 7/22). According to the revised bill, the patient consent provision would be implemented two years after the bill is enacted, and HHS would be required to develop “reasonable and workable” rules to implement the provision.
The original version of the bill also would have required health care providers to notify patients of any unauthorized acquisition, access or disclosure of their health care information. The revised version states that a “good faith” disclosure, such as a mislabeled letter with a wrong address, would not be considered a breach.
Other revised provisions in the bill would:
Prohibit the sale of patients’ records without consent unless it is necessary for treatment or to receive payment for treatment;
Change existing federal privacy laws to allow for the provision of a no-cost digital copy of an individual’s medical record;
Strengthen language to ban direct and indirect payments to providers who advertise health care products to patients without permission; and
Require the HHS Office of Civil Rights to launch a formal investigation of complaints and allow the office to impose fines for violations deemed “willful neglect” (Noyes, CongressDaily, 7/22).
Comments
House Energy and Commerce Subcommittee on Health ranking member Nathan Deal (R-Ga.) said the bill could advance on Wednesday. Deal said, “I think we worked out most of the big issues, barring amendments that come in and change that balance,” adding, “Assuming the mark up goes fairly smoothly this week … we probably would see it maybe even in the form of a suspension on the floor” (Armstrong, CQ Today, 7/22).
Mary Grealy, president of the Healthcare Leadership Council — who on Monday sent a letter to Dingell and Barton stating her concerns about the proposed bill’s effect on the Confidentiality Coalition — said, “They did make improvements in those provisions we had some concerns about, so I do feel like we’re making progress.” However, she added, “Do I think they have completely addressed all the issues? No” (The Hill, 7/22).
A spokesperson for America’s Health Insurance Plans said the provision that would allow patients to access their medical records and require them to provide consent for third-party access could restrict health care providers from developing wellness, disease management, quality assurance and other essential programs (CongressDaily, 7/22). A spokesperson for Patient Privacy Rights said the revised bill is being reviewed and declined comment (The Hill, 7/22).
Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.
Under the revised bill, patients would give their consent only once to health care companies that want to access health care records without identifying information for HHS-approved purposes, such as hospital audits or fraud and abuse allegations. The bill previously would have required patient consent each time the records were accessed (Young, The Hill, 7/22). According to the revised bill, the patient consent provision would be implemented two years after the bill is enacted, and HHS would be required to develop “reasonable and workable” rules to implement the provision.
The original version of the bill also would have required health care providers to notify patients of any unauthorized acquisition, access or disclosure of their health care information. The revised version states that a “good faith” disclosure, such as a mislabeled letter with a wrong address, would not be considered a breach.
Other revised provisions in the bill would:
Prohibit the sale of patients’ records without consent unless it is necessary for treatment or to receive payment for treatment;
Change existing federal privacy laws to allow for the provision of a no-cost digital copy of an individual’s medical record;
Strengthen language to ban direct and indirect payments to providers who advertise health care products to patients without permission; and
Require the HHS Office of Civil Rights to launch a formal investigation of complaints and allow the office to impose fines for violations deemed “willful neglect” (Noyes, CongressDaily, 7/22).
Comments
House Energy and Commerce Subcommittee on Health ranking member Nathan Deal (R-Ga.) said the bill could advance on Wednesday. Deal said, “I think we worked out most of the big issues, barring amendments that come in and change that balance,” adding, “Assuming the mark up goes fairly smoothly this week … we probably would see it maybe even in the form of a suspension on the floor” (Armstrong, CQ Today, 7/22).
Mary Grealy, president of the Healthcare Leadership Council — who on Monday sent a letter to Dingell and Barton stating her concerns about the proposed bill’s effect on the Confidentiality Coalition — said, “They did make improvements in those provisions we had some concerns about, so I do feel like we’re making progress.” However, she added, “Do I think they have completely addressed all the issues? No” (The Hill, 7/22).
A spokesperson for America’s Health Insurance Plans said the provision that would allow patients to access their medical records and require them to provide consent for third-party access could restrict health care providers from developing wellness, disease management, quality assurance and other essential programs (CongressDaily, 7/22). A spokesperson for Patient Privacy Rights said the revised bill is being reviewed and declined comment (The Hill, 7/22).
Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.
Thursday, July 24, 2008
$60 Million to Settle False Claims Act and they still are BILLING!!!
What is wrong with this picture?
And they are allowed to still OPERATE and BILL MEDICARE/MEDICAID!!!
As part of the $60 million settlement, Cox has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services (HHS) Office of Inspector General. The Corporate Integrity Agreement contains measures to ensure compliance with Medicare regulations and policies in the future.
Missouri Health Care System to Pay U.S. $60 Million to Settle False Claims Act Allegations
July 23, 2008
Lester E. Cox Medical Centers, a health care system headquartered in Springfield, Mo., has agreed to pay the United States to settle claims that it violated the False Claims Act, the Anti-Kickback Statute and the Stark Statute between 1996 and 2005, by entering into certain financial relationships with referring doctors at a local physician group and engaging in improper billing practices with respect to Medicare. Cox, a not-for-profit healthcare organization, will pay the United States $60 million to resolve these claims.
Under the Stark Statute, Medicare providers like Cox are prohibited from billing the federal health care program for referrals from doctors with whom the providers have a financial relationship, unless that relationship falls within certain exceptions. The United States contended that certain relationships between Cox and physicians ran afoul of the Anti-Kickback Statute, which prohibits offering inducements to providers in return for patient referrals, and the Stark statute. Additional claims being resolved concern Cox’s inclusion of non-reimbursable costs on its Medicare cost reports and improper billings for services provided to dialysis patients.
“The Justice Department is committed to ensuring that the best interests of federal health care program patients are not compromised by unlawful payments to physicians,” said Gregory G. Katsas, Assistant Attorney General for the Justice Department’s Civil Division. “The resolution of this matter resulted in a significant recovery for taxpayers, and it exemplifies our dedication to vigorous enforcement of the Stark and Anti-Kickback Statutes.”
As part of the $60 million settlement, Cox has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services (HHS) Office of Inspector General. The Corporate Integrity Agreement contains measures to ensure compliance with Medicare regulations and policies in the future.
“Today’s settlement furthers both our commitment to protecting patients from improper billing practices and the continued ability of Cox to provide quality medical care in Springfield and the Ozarks,” said John F. Wood, U.S. Attorney in Kansas City, Mo. “I am pleased that we were able to resolve this matter without litigation.”
The settlement with Cox was the result of a coordinated effort by the Commercial Litigation Branch of the Justice Department’s Civil Division; the U.S. Attorney’s Office for the Western District of Missouri; HHS’ Office of Inspector General, Office of Counsel to the Inspector General, and Office of Audit Services; and the FBI.
Source: DoJ
And they are allowed to still OPERATE and BILL MEDICARE/MEDICAID!!!
As part of the $60 million settlement, Cox has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services (HHS) Office of Inspector General. The Corporate Integrity Agreement contains measures to ensure compliance with Medicare regulations and policies in the future.
Missouri Health Care System to Pay U.S. $60 Million to Settle False Claims Act Allegations
July 23, 2008
Lester E. Cox Medical Centers, a health care system headquartered in Springfield, Mo., has agreed to pay the United States to settle claims that it violated the False Claims Act, the Anti-Kickback Statute and the Stark Statute between 1996 and 2005, by entering into certain financial relationships with referring doctors at a local physician group and engaging in improper billing practices with respect to Medicare. Cox, a not-for-profit healthcare organization, will pay the United States $60 million to resolve these claims.
Under the Stark Statute, Medicare providers like Cox are prohibited from billing the federal health care program for referrals from doctors with whom the providers have a financial relationship, unless that relationship falls within certain exceptions. The United States contended that certain relationships between Cox and physicians ran afoul of the Anti-Kickback Statute, which prohibits offering inducements to providers in return for patient referrals, and the Stark statute. Additional claims being resolved concern Cox’s inclusion of non-reimbursable costs on its Medicare cost reports and improper billings for services provided to dialysis patients.
“The Justice Department is committed to ensuring that the best interests of federal health care program patients are not compromised by unlawful payments to physicians,” said Gregory G. Katsas, Assistant Attorney General for the Justice Department’s Civil Division. “The resolution of this matter resulted in a significant recovery for taxpayers, and it exemplifies our dedication to vigorous enforcement of the Stark and Anti-Kickback Statutes.”
As part of the $60 million settlement, Cox has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services (HHS) Office of Inspector General. The Corporate Integrity Agreement contains measures to ensure compliance with Medicare regulations and policies in the future.
“Today’s settlement furthers both our commitment to protecting patients from improper billing practices and the continued ability of Cox to provide quality medical care in Springfield and the Ozarks,” said John F. Wood, U.S. Attorney in Kansas City, Mo. “I am pleased that we were able to resolve this matter without litigation.”
The settlement with Cox was the result of a coordinated effort by the Commercial Litigation Branch of the Justice Department’s Civil Division; the U.S. Attorney’s Office for the Western District of Missouri; HHS’ Office of Inspector General, Office of Counsel to the Inspector General, and Office of Audit Services; and the FBI.
Source: DoJ
Monday, July 21, 2008
The largest prosecution of a home-health-care agency in Virginia
OK!!
GET THIS!!
Nurse pleads guilty to Medicaid fraud
Zavelsky admitted she defrauded Medicaid by submitting false claims for payment.
Total billings for Renaissance to Virginia Medicaid totaled more than $14 million
Zavelsky is facing a maximum of 10 years in prison and a $250,000 fine. Renaissance faces a fine of up to $500,000.
($500,000.+$250,000 = $750,000) Where is the MONEY? $14 MILLION in Billing (remember, we are reading about THIEVES and very Cunning People.)
Hmm.....$14MILLION minus $750,000 = GOOD WORK FOR HOW MNAY YEARS IN PRISON?
TEN? I doubt it. Will be very interesting to see how many years for this PROFIT!
As part of the plea agreement, Zavelsky's husband, Ilya Zavelsky, 46, a physician, was dismissed from the case. The couple live in Glen Allen, and their company provided respite care and other services to Russian-speaking communities in Virginia
Nurse pleads guilty to Medicaid fraud
Billings exceeded $14 million; husband dismissed from case
Saturday, Jul 19, 2008 - 12:08 AM
TIMES-DISPATCH STAFF WRITER
The largest prosecution of a home-health-care agency in Virginia ended in guilty pleas yesterday in federal court.
Rina Zavelsky, 40, a nurse, and her company, Renaissance Inc., pleaded guilty to one count of conspiracy to commit health-care fraud before U.S. District Judge Richard L. Williams.
They will be sentenced Oct. 24. Zavelsky is facing a maximum of 10 years in prison and a $250,000 fine. Renaissance faces a fine of up to $500,000.
As part of the plea agreement, Zavelsky's husband, Ilya Zavelsky, 46, a physician, was dismissed from the case. The couple live in Glen Allen, and their company provided respite care and other services to Russian-speaking communities in Virginia.
They were indicted this year for conspiracy to commit health-care fraud and money laundering. In pleading guilty yesterday, Zavelsky admitted she defrauded Medicaid by submitting false claims for payment.
She acknowledged providing services through unqualified and untrained personal care aides and making false training certificates to cover up the lack of training. The Virginia Department of Medical Assistance discovered the violations in 2003 and 2007.
From 2002 to its closing in 2008, Renaissance employed more than 350 aides acting as independent contractors and made billings for more than 250 Medicaid recipients in the Richmond, Tidewater, Harrisonburg and Northern Virginia areas.
Total billings for Renaissance to Virginia Medicaid totaled more than $14 million.
The case was investigated by the FBI, the U.S. Internal Revenue Service and the Virginia Attorney General's Office.
Virginia Attorney General Bob McDonnell said, "This is an important step forward in ensuring the future of the Medicaid system in the commonwealth."
Chuck Rosenberg, the U.S. attorney for the Eastern District of Virginia, lauded the close work of state and federal agencies in investigating the case. It was prosecuted by Brian Whisler, an assistant U.S. attorney, and Assistant Virginia Attorneys General Dale Mullen and Eric Atkinson.
Contact Frank Green at (804) 649-6340 or fgreen@timesdispatch.com.
GET THIS!!
Nurse pleads guilty to Medicaid fraud
Zavelsky admitted she defrauded Medicaid by submitting false claims for payment.
Total billings for Renaissance to Virginia Medicaid totaled more than $14 million
Zavelsky is facing a maximum of 10 years in prison and a $250,000 fine. Renaissance faces a fine of up to $500,000.
($500,000.+$250,000 = $750,000) Where is the MONEY? $14 MILLION in Billing (remember, we are reading about THIEVES and very Cunning People.)
Hmm.....$14MILLION minus $750,000 = GOOD WORK FOR HOW MNAY YEARS IN PRISON?
TEN? I doubt it. Will be very interesting to see how many years for this PROFIT!
As part of the plea agreement, Zavelsky's husband, Ilya Zavelsky, 46, a physician, was dismissed from the case. The couple live in Glen Allen, and their company provided respite care and other services to Russian-speaking communities in Virginia
Nurse pleads guilty to Medicaid fraud
Billings exceeded $14 million; husband dismissed from case
Saturday, Jul 19, 2008 - 12:08 AM
TIMES-DISPATCH STAFF WRITER
The largest prosecution of a home-health-care agency in Virginia ended in guilty pleas yesterday in federal court.
Rina Zavelsky, 40, a nurse, and her company, Renaissance Inc., pleaded guilty to one count of conspiracy to commit health-care fraud before U.S. District Judge Richard L. Williams.
They will be sentenced Oct. 24. Zavelsky is facing a maximum of 10 years in prison and a $250,000 fine. Renaissance faces a fine of up to $500,000.
As part of the plea agreement, Zavelsky's husband, Ilya Zavelsky, 46, a physician, was dismissed from the case. The couple live in Glen Allen, and their company provided respite care and other services to Russian-speaking communities in Virginia.
They were indicted this year for conspiracy to commit health-care fraud and money laundering. In pleading guilty yesterday, Zavelsky admitted she defrauded Medicaid by submitting false claims for payment.
She acknowledged providing services through unqualified and untrained personal care aides and making false training certificates to cover up the lack of training. The Virginia Department of Medical Assistance discovered the violations in 2003 and 2007.
From 2002 to its closing in 2008, Renaissance employed more than 350 aides acting as independent contractors and made billings for more than 250 Medicaid recipients in the Richmond, Tidewater, Harrisonburg and Northern Virginia areas.
Total billings for Renaissance to Virginia Medicaid totaled more than $14 million.
The case was investigated by the FBI, the U.S. Internal Revenue Service and the Virginia Attorney General's Office.
Virginia Attorney General Bob McDonnell said, "This is an important step forward in ensuring the future of the Medicaid system in the commonwealth."
Chuck Rosenberg, the U.S. attorney for the Eastern District of Virginia, lauded the close work of state and federal agencies in investigating the case. It was prosecuted by Brian Whisler, an assistant U.S. attorney, and Assistant Virginia Attorneys General Dale Mullen and Eric Atkinson.
Contact Frank Green at (804) 649-6340 or fgreen@timesdispatch.com.
Medicaid False Claims Act Amendment Stalls ....
Posted On: July 19, 2008 by David L. Haron
Michigan Medicaid False Claims Act Amendment Stalls Because of Petty Legislative Political Bickering
As I reported earlier, the Michigan Medicaid False Claims Act was amended effective January 1, 2006 through the efforts of Attorney General Mike Cox and Representative David Law (R., Commerce). I worked actively for passage of the amendment and testified before the Michigan House of Representative Judiciary committee, then chaired by Rep. Law..
The State of Michigan can recoup extra funds from combined state/federal recoveries because of the provisions of the federal Deficit Reduction Act of 2005 ('DRA"). To explain, shortly after the the Michigan Medicaid False Claims Act amendment passed the Michigan Legislature and Governor Granholm signed the Act, the U.S. Congress passed the DRA providing for a 10% incentive to States which enacted a "compliant" Qui Tam statute addressing Medicaid fraud. Specifically, the Medicaid program is a joint federal/state program. Thus, in Michigan, the federal government pays about 56% and the state 44% of the costs of the Medicaid program and fraud recoveries are divided on the same percentage.
If the state has a "compliant" Qui Tam statute, the state receives an extra 10% of the recovery--that is, 54% in Michigan--of the recovery--instead of 44%--a significant amount of money since most recoveries are in the tens of millions of dollars or more!!
However, on December 21, 2006, the U.S, Department of Health and Human Services/Office of Inspector General ("HHS/OIG") advised the state, by letter, that its Medicaid False Claims Act was NOT "DRA compliant" (that is, a mirror image of the federal False Claims Act).
In order to comply, all that was needed was a simple bill adding civil monetary penalties of at least $5000 for each violation and making one other technical amendment. Since the revisions would not have had any negative fiscal impact on the state and would have had a potentially tremendous positive impact in the event of any recovery, one would have expected Representative Law to quickly introduce a clarification/modification bill and obtain quick passage--after all, the State would most certainly not turn down the opportunity to reverse the flow of funds from Michigan to Washington??
Unfortunately, in 2006 and 2007, petty partisan bickering was rampant in the Michigan Legislature--we were paralyzed by the absurd budget fight and leadership was non-existent.
Rep. Law, finally, on September 17, 2007, introduced a one-page bill. The date of introduction is significant. In addition to being a Saturday, the day of the Notre Dame-UM football game (a game, I suspect, Rep. Law, a Notre Dame grad, was attending), it was three days before Ray Sayeh, then a WXYZ-TV investigative reporter, had scheduled (at my request) an interview with the representative to discuss the failure to take action on the revisions.
Unfortunately, again because of partisanship and Democratic control of the House of Representatives, the bill went nowhere while the Attorney General continued to obtain recoveries from fraud-feasors and the unclaimed 10% incentive was lost to Washington.
Finally, on February 19, 2008, Representative Marc Courveau (D., Northville) introduced HB 5757. The amended FCA, as presented in HB 5757, would allow the Michigan FCA to become DRA compliant. Once again, the small changes made by HB 5757, as required by the federal HHS/OIG., would cost the state nothing in administrative or other costs and would bring millions of dollars in the future back from Washington.
HB 5757 quickly passed the House with NO opposition and was sent to the Senate.
Tragically, because of continued political maneuvering, the Bill sits in the Judiciary Committee.
It seems that Rep. Courveau was elected at the expense of a Republican and the leadership of the Judiciary Committee and Senate Majority Leader, Mike Bishop will not allow this largely unopposed, fiscally responsible bill, to be brought up at the committee or floor level because it would give "points" to Rep. Courveau!!!!
The State of Michigan is in a deep recession/depression, unemployment sits at 8.5%, the highest in the nation, GM is in deep trouble, the City of Detroit is selling assets and landmarks--such at the Detroit-Windsor tunnel--and the Legislature cannot pass a one-page bill that will bring money to the state and its Medicaid recipients.
This Bill is under the radar, unfortunately--Ray (now Rez) Sayeh has joined CNN International and is posted in Pakistan, columnists such as Brian Dickerson and others have been unresponsive despite my entreaties, my solicitations to the Legislature and the use of my contacts have been unavailing.
I am frustrated. Medicaid fraud is rampant, the Attorney General is acting diligently in pursuing the cheaters, and we have been filing qui tam cases under the new Act, but even if all of these activities are successful--and they will be--the State will not receive the full benefit of its recoveries!!!
Michigan Medicaid False Claims Act Amendment Stalls Because of Petty Legislative Political Bickering
As I reported earlier, the Michigan Medicaid False Claims Act was amended effective January 1, 2006 through the efforts of Attorney General Mike Cox and Representative David Law (R., Commerce). I worked actively for passage of the amendment and testified before the Michigan House of Representative Judiciary committee, then chaired by Rep. Law..
The State of Michigan can recoup extra funds from combined state/federal recoveries because of the provisions of the federal Deficit Reduction Act of 2005 ('DRA"). To explain, shortly after the the Michigan Medicaid False Claims Act amendment passed the Michigan Legislature and Governor Granholm signed the Act, the U.S. Congress passed the DRA providing for a 10% incentive to States which enacted a "compliant" Qui Tam statute addressing Medicaid fraud. Specifically, the Medicaid program is a joint federal/state program. Thus, in Michigan, the federal government pays about 56% and the state 44% of the costs of the Medicaid program and fraud recoveries are divided on the same percentage.
If the state has a "compliant" Qui Tam statute, the state receives an extra 10% of the recovery--that is, 54% in Michigan--of the recovery--instead of 44%--a significant amount of money since most recoveries are in the tens of millions of dollars or more!!
However, on December 21, 2006, the U.S, Department of Health and Human Services/Office of Inspector General ("HHS/OIG") advised the state, by letter, that its Medicaid False Claims Act was NOT "DRA compliant" (that is, a mirror image of the federal False Claims Act).
In order to comply, all that was needed was a simple bill adding civil monetary penalties of at least $5000 for each violation and making one other technical amendment. Since the revisions would not have had any negative fiscal impact on the state and would have had a potentially tremendous positive impact in the event of any recovery, one would have expected Representative Law to quickly introduce a clarification/modification bill and obtain quick passage--after all, the State would most certainly not turn down the opportunity to reverse the flow of funds from Michigan to Washington??
Unfortunately, in 2006 and 2007, petty partisan bickering was rampant in the Michigan Legislature--we were paralyzed by the absurd budget fight and leadership was non-existent.
Rep. Law, finally, on September 17, 2007, introduced a one-page bill. The date of introduction is significant. In addition to being a Saturday, the day of the Notre Dame-UM football game (a game, I suspect, Rep. Law, a Notre Dame grad, was attending), it was three days before Ray Sayeh, then a WXYZ-TV investigative reporter, had scheduled (at my request) an interview with the representative to discuss the failure to take action on the revisions.
Unfortunately, again because of partisanship and Democratic control of the House of Representatives, the bill went nowhere while the Attorney General continued to obtain recoveries from fraud-feasors and the unclaimed 10% incentive was lost to Washington.
Finally, on February 19, 2008, Representative Marc Courveau (D., Northville) introduced HB 5757. The amended FCA, as presented in HB 5757, would allow the Michigan FCA to become DRA compliant. Once again, the small changes made by HB 5757, as required by the federal HHS/OIG., would cost the state nothing in administrative or other costs and would bring millions of dollars in the future back from Washington.
HB 5757 quickly passed the House with NO opposition and was sent to the Senate.
Tragically, because of continued political maneuvering, the Bill sits in the Judiciary Committee.
It seems that Rep. Courveau was elected at the expense of a Republican and the leadership of the Judiciary Committee and Senate Majority Leader, Mike Bishop will not allow this largely unopposed, fiscally responsible bill, to be brought up at the committee or floor level because it would give "points" to Rep. Courveau!!!!
The State of Michigan is in a deep recession/depression, unemployment sits at 8.5%, the highest in the nation, GM is in deep trouble, the City of Detroit is selling assets and landmarks--such at the Detroit-Windsor tunnel--and the Legislature cannot pass a one-page bill that will bring money to the state and its Medicaid recipients.
This Bill is under the radar, unfortunately--Ray (now Rez) Sayeh has joined CNN International and is posted in Pakistan, columnists such as Brian Dickerson and others have been unresponsive despite my entreaties, my solicitations to the Legislature and the use of my contacts have been unavailing.
I am frustrated. Medicaid fraud is rampant, the Attorney General is acting diligently in pursuing the cheaters, and we have been filing qui tam cases under the new Act, but even if all of these activities are successful--and they will be--the State will not receive the full benefit of its recoveries!!!
RAC Contractors to be Identified, Recovery Asset Contractor
RAC Contractors to be Identified
Posted on July 19, 2008 by Executive-Post
CMS Aims to Reduce Fraud
Staff Writers
This month, the Centers for Medicare and Medicaid Services [CMS] will name the auditing firms that will review hospitals’ books for payment mistakes, while hospital officials say results in other states suggest the auditors will give priority to recovering overpayments.
The RAC Program
Under the so-called Recovery Asset Contractor [RAC] program, CMS pays auditors a fee based on the amount of improper payments discovered.
Hospital officials worry this “bounty hunter” approach - the second for CMS after medical practice audits - will create a bias in auditors to focus only on collecting government overpayments, reported the Pittsburgh Business Times on June 16, 2008.
Pilot Program Results
Some hospitals point to a pilot audit program in New York, Florida and California, which found $357.2 million in overpayments and just $14.3 million in underpayments. Medicare estimates its error rate at 3.9 percent in 2007, down from 9.8 percent in 2003, but still totaling $10.8 billion in improper payments
Conclusion
Your thoughts and comments are appreciated. Is this another instance of brute intimidation or just honest review
Posted on July 19, 2008 by Executive-Post
CMS Aims to Reduce Fraud
Staff Writers
This month, the Centers for Medicare and Medicaid Services [CMS] will name the auditing firms that will review hospitals’ books for payment mistakes, while hospital officials say results in other states suggest the auditors will give priority to recovering overpayments.
The RAC Program
Under the so-called Recovery Asset Contractor [RAC] program, CMS pays auditors a fee based on the amount of improper payments discovered.
Hospital officials worry this “bounty hunter” approach - the second for CMS after medical practice audits - will create a bias in auditors to focus only on collecting government overpayments, reported the Pittsburgh Business Times on June 16, 2008.
Pilot Program Results
Some hospitals point to a pilot audit program in New York, Florida and California, which found $357.2 million in overpayments and just $14.3 million in underpayments. Medicare estimates its error rate at 3.9 percent in 2007, down from 9.8 percent in 2003, but still totaling $10.8 billion in improper payments
Conclusion
Your thoughts and comments are appreciated. Is this another instance of brute intimidation or just honest review
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