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Vol. VIII, No. 36 – October 27, 2006 | Contact: Margaret Dragon, Editor, (781) 593-4924
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Table of Contents

Headlines

Keystone Mercy Health Plan Settlement Announced
Medco Settlement Announced
Maryland Psychiatrist Sentenced
Executive Charged With Fraud
Florida Couple Plead Guilty to Fraud
Texas DME Owner Convicted of Health Care Fraud

Regulatory News

In the Federal Register
CMS Transmittals
From the OIG

This Week’s Link
Acronym Library

Visit HCCA's Web site
HCCA Headquarters - Contact Information

Headlines:

Keystone Mercy Health Plan Settlement Announced
Acting U.S. Attorney for the Eastern District of Pennsylvania Laurie Magid announced on October 26, 2006 that Keystone Mercy Health Plan has agreed to pay $5 million to resolve civil liabilities under the federal False Claims Act and other federal and state statutes and common law principles.

Keystone Mercy Health Plan is a Pennsylvania partnership that operates a managed care plan for thousands of Medical Assistance recipients pursuant to a contract with the Pennsylvania Department of Public Welfare (DPW). As part of its contract with DPW, Keystone Mercy Health Plan was responsible for paying healthcare providers for services rendered to qualified Medicaid recipients. Keystone Mercy Health Plan was also responsible for preventing and recovering overpayments to providers in instances where other programs and carriers were responsible for part of the cost of such services. The contract also required Keystone Mercy Health Plan, under certain circumstances, to return overpayments to DPW. From 1997 though 1998, Keystone Mercy Health Plan failed to return such overpayments to DPW. For more:
http://www.usdoj.gov/usao/pae/News/Pr/2006/ oct/Keystonepress.html

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Medco Settlement Announced
On October 23, the U.S. Department of Justice announced that Medco Health Solutions has agreed to pay the United States $155 million plus interest to settle allegations that the Parsippany, N.J.-based company submitted false claims to the government, solicited and accepted kickbacks from pharmaceutical manufacturers to favor their drugs, and paid kickbacks to health plans to obtain business, the Justice Department announced today. Medco, the nation’s second largest pharmacy benefit management company, manages the prescription drug benefits of over 60 million Americans, including millions of Medicare beneficiaries. For more:
http://www.usdoj.gov/opa/pr/2006/October/06_civ_722.html

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Maryland Psychiatrist Sentenced
On October 17, Maryland Attorney General, J. Joseph Curran, Jr. announced that Dr. Opauraugo Ihentuge Udebiuwa, a psychiatrist, was sentenced to three years incarceration, suspending all but 12 months to be served as home detention, for defrauding the Medicaid Program by billing Medicaid for services that were never provided. Baltimore City Circuit Court Judge Lynn K. Stewart also ordered Udebiuwa, 47, of the 400 block of West Central Avenue in Davidsonville, Maryland to pay $32,000 restitution to the Medicaid Program and to pay a penalty of $64,000, representing total payment of $96,000. Judge Stewart also placed Udebiuwa on three years probation, which will be supervised until that time when he makes full restitution and unsupervised thereafter.  For more: http://www.oag.state.md.us/Press/2006/101706b.htm

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Executive Charged With Fraud
According to a report in the October 19, Wisconsin State Journal “A Philippines corporation and its chief executive officer defrauded the U.S. military's health-care program of nearly $1 million, according to a 75-count indictment unsealed Tuesday in U.S. District Court in Madison. The indictment was returned by a grand jury in July 2005 but was sealed until Thomas Arthur Lutz, 39, of Olongapo City, Philippines, appeared Tuesday in a court in Guam. It alleges that Lutz, who is an American citizen, and Health Visions Corp. devised a scheme to defraud the federal Tricare program and charges them with 32 counts of mail fraud, 41 counts of filing a false claim, one count of conspiracy and a forfeiture count.

“The indictment was brought in Madison because Wisconsin Physicians Service processed and paid the alleged fraudulent claims for Tricare, which provides health-care benefits for active and retired U.S. military personnel worldwide.

“According to the indictment, between October 1998 and August 2004 Lutz and Health Visions entered into a kickback scheme with a medical provider in the Philippines which paid 50 percent of the billed amount for Tricare patients back to Health Visions. Lutz and Health Visions also allegedly inflated the bills of other providers by at least 100 percent before submitting them for payment.

“Lutz and Health Visions also allegedly created a sham insurance program to circumvent Tricare deductible requirements and submitted fictitious Tricare claims, the indictment alleges.”

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Florida Couple Plead Guilty to Fraud
On October 18, U.S. Attorney for the Southern District of Florida R. Alexander Acosta announced that Rita Cardoso and her husband, Luis Delgado, of Miami, owners and operators of several health care related businesses located in Miami-Dade County, pled guilty before United States District Court Judge Jose E. Martinez in Miami, Florida. Cardoso and Delgado were charged in separate cases with defrauding the Medicare Program of more than 4 million dollars through fraudulent billings for durable medical equipment. Durable medical equipment (DME) is equipment that is designed for repeated use and for a medical purpose and include items such as prosthetic limbs, back braces, knee braces, and wheelchairs. Cardoso and Delgado billed Medicare for more than $17 million for the equipment which they allegedly provided to their customers. Cardoso and Delgado were also charged with structuring withdrawals of Medicare funds for under $10,000 to avoid having the banks file currency transaction reports with the Department of Treasury. Cardoso and Delgado also plead guilty to conspiracy to commit wire and mail fraud charges in a separate Information. For more:
http://www.usdoj.gov/usao/fls/PressReleases/061018-01.html

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Texas DME Owner Convicted of Health Care Fraud
On October 18, the U.S. Attorney for the Southern District of Texas Don DeGabrielle announced that “The owner of Makey Medical Sales and Supplies, a durable medical supply company in Sugarland, Texas, was convicted of conspiracy and health care fraud as a result of an ongoing investigation into what has become knows as a "wheelchair scam,"  For more:
http://www.usdoj.gov/usao/txs/releases/October2006/061018-Etim.htm

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This week, MediRegs provided TWCC readers with the following Regulatory information: In the Federal Register, CMS Transmittals, and From the OIG.

Regulatory News

In the Federal Register
Final Rule Sets Part B Premium Allotments for States
In a final rule published October 16, 2006, CMS set forth the methodology and process used to compute and issue each State's allotments for fiscal years 2006 and 2007 that are available to pay Medicare Part B premiums for qualifying individuals. The rule also provides the final FY 2006 allotments and the preliminary FY 2007 allotments determined under this methodology.
71 CFR 60663:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_fr69_cms&u=0610166&h=top1.html&t=80&s=twcc

CMS Proposes Using Part D Data for Other Purposes
On October 18, 2006, CMS proposed a rule that would allow the Secretary to use the claims information that is being collected for Part D payment purposes for other research, analysis, reporting, and public health functions. CMS states the Secretary needs to use this data because other publicly available data is insufficient for the studies and operations required to oversee the program, protect the public health, and respond to Congressional mandates.
71 CFR 61445:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_fr69_cms&u=0610184&h=top1.html&t=80&s=twcc

Proposed Rule Would Require Sprinkler Systems in LTC Facilities
In the October 27, 2006 Federal Register, CMS proposed a rule that would allow require all long term care facilities to be equipped with sprinkler systems. This proposed rule especially requests public comments on the duration of a phase-in period to allow long term care facilities to install such systems. 71 CFR 62957 http://a257.g.akamaitech.net/7/257/2422/01jan20061800/ edocket.access.gpo.gov/2006/E6-17911.htm

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CMS Transmittals
Medicare Claims Processing (PUB. 100-04)
Transmittal #1078, Updating the Medicare Secondary Payer Manual for Consistency on Instructing Part A Contactors on Handling MSP Claims with Condition Code 08:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04& u=mrepm10004r1078cp&h=top1.html&t=80&s=twcc
Transmittal #1077, Electronic Data Interchange Media Changes:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04& u=mrepm10004r1077cp&h=top1.html&t=80&s=twcc
Transmittal #1076, Competitive Acquisition Program Instructions on Special CAP Appeals Requirements and Delivery of Dispute Resolution Services:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_pm_100_04& u=mrepm10004r1076cp&h=top1.html&t=80&s=twcc

Medicare Secondary Payer (PUB. 100-05)
Transmittal #56, Updating the Medicare Secondary Payer Manual for Consistency on Instructing Part A Contactors on Handling MSP Claims with Condition Code 08:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_mr_mspm& u=mremrmspmr56msp&h=top1.html&t=80&s=twcc

National Coverage Analyses
Carotid Artery Stenting Facilities - 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=carotidarterystentinglist15&h=top1.html&t=80&s=twcc
PET for Dementia Trials - 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=dementialist&h=top1.html&t=80&s=twcc
Lung Volume Reduction Surgery - 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=lvrslist&h=top1.html&t=80&s=twcc
National Oncologic PET Registry - 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=noprlist&h=top1.html&t=80&s=twcc
VAD Destination Therapy Facilities - 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=vadlist&h=top1.html&t=80&s=twcc
Medicare Coverage Advisory Committee Meetings - 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=mcacmeetings&h=top1.html&t=80&s=twcc
Glycated Hemoglobin/Glycated Protein (Addition of ICD-9-CM 271.3, Intestinal disaccharidase deficiencies and disaccharide malabsorption) (CAG-00336N) - Expected Completion Date: 10/20/06:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_nca& u=CALCAG00336N&h=top1.html&t=80&s=twcc

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From the OIG
OIG Advisory Opinion No. 06-17 - regarding payment of certain compensation owed by the organizer of a dental preferred provider organization to a dental network marketing and management company in connection with the use of the dental network by a Federal employee health benefits:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= hc_ig_ao&u=ao0617&h=top1.html&t=80&s=twcc

Audit Reports
Review of Comprehensive Outpatient Rehabilitation Facility Therapy Services Provided by ABC Total Rehabilitation Care, Inc. (A-04-04-02011; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=40402011&h=top1.html&t=80&s=twcc
Review of Medicaid Community Mental Health Provider Services In Illinois (A-05-05-00055; 09/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=50500055&h=top1.html&t=80&s=twcc
Duplicate Medicare Payments to Cost-Based Health Maintenance Plan Excellus Health Plan for the Fiscal Years 2002, Through 2004 (A-05-06-00030; 09/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=50600030&h=top1.html&t=80&s=twcc
Review of Compliance With Billing Provisions Under The Prospective Payment System For Home Health Agencies' Therapy Services - Pacific Home Health Care, Inc. (A-05-04-00103; 09/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=50400103&h=top1.html&t=80&s=twcc
Review of Excess Benefit Plan Costs Claimed by CIGNA for Medicare Reimbursement for Fiscal Years 1991 Through 2004 (A-07-06-00215; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=70600215&h=top1.html&t=80&s=twcc
Review of Accounts Receivable at the IHS Billings Area Office (A-07-06-01023; 10/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=70601023&h=top1.html&t=80&s=twcc
Report on the Medicare Drug Discount Card Program Sponsor Medco Health Solutions (A-06-05-00066; 09/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=60500066&h=top1.html&t=80&s=twcc
Review of Medicare Contractor Information Security Program Evaluations for Fiscal Year 2004 (A-18-05-02600; 09/2006):
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c= mre_oig_oas_cms2005&u=180502600&h=top1.html&t=80&s=twcc

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This Week’s Links:
Medco Corporate Integrity Agreement
http://oig.hhs.gov/fraud/cia/index.html

OIG Other Guidance
Physician Investments in Medical Device Manufacturers and Distributors
http://oig.hhs.gov/fraud/fraudalerts.html#3

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Acronym Library

For more from CMS Acronyms: http://www.cms.hhs.gov/acronyms/listall.asp

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Visit HCCA's Web site, http://www.hcca-info.org

NOTE: HCCA Members please contact April Kiel at april.kiel@hcca-info.org
if you have not received your password. This new Web site allows members and visitors to register for conferences, order products, or join HCCA online. HCCA Members can update membership information and search for compliance resources online in a secure environment, without faxing, emailing and other time-consuming activities.HCCA's Web site also offers E-Communities, which allow regional and industry specific information to be shared through a discussion forum and list-serve. Members can view and respond to documents, tools, forms, policies and other information posted by Regional and Compliance Focus Group leaders!
Visit http://www.hcca-info.org and see for yourself.

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HCCA Headquarters - Contact Information Your HCCA Office is located at:
6500 Barrie Road, Suite 250
Minneapolis, MN 55435
The HCCA Toll-Free 888/580-8373,
Fax number - (952) 988-0146
MN telephone number- (952) 988-0141
Email - info@hcca-info.org Contact: Margaret Dragon, Editor
This Week in Corporate Compliance (781) 593-4924

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