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This Week’s Headlines – January 8, 2016

Florida woman died after hospital thought she was faking: lawyers

St. Luke's insurer ordered to cover legal fees

Health care fraud charges and plea agreements filed against physician and two others

Research: Not nearly as transparent as it needs to be

Owner of three Los Angeles clinics sentenced to 78 months in prison for Medicare fraud

San Diego genetics laboratory pays $4 million to settle federal kickback allegations in connection with patient referrals

CVS among hundreds of providers violating HIPAA, review finds

Government health care fraud recoveries slide

Government settles alleged False Claims Act violations with Memorial Health, Inc.

U.S. settles with Aria Health Systems over unnecessary invasive procedures and improper compensation claims

Clinical director of home care agency sentenced in Medicare fraud scheme

Coloplast Corp. and Liberator Medical agree to pay $3.6 million to resolve kickback allegations

This Week’s Links

Regulatory News

CMS Update

CMS Transmittals

Acronym Library

Headlines

Florida woman died after hospital thought she was faking: lawyers
On January 7, 2016, Reuters reported, "A Florida woman who collapsed and later died after being arrested for refusing to leave a rural hospital emergency room may have lived if medical staff and police had not assumed she was faking illness, her lawyers said on Wednesday.

"Barbara Dawson, 57, complained of abdominal pains at Calhoun Liberty Hospital in the Florida Panhandle town of Blountstown five days before Christmas, but medical staff examined and released her.

"When she refused to leave, the hospital called the police, who handcuffed her and took her outside, where she collapsed in the hospital driveway. Dawson was returned to the hospital but died of a blood clot in her lungs the next day." For more

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St. Luke's insurer ordered to cover legal fees
On January 6, 2016, Idaho Statesman reported, "The insurance company that St. Luke's Health System sued more than a year ago, alleging breach of contract, has been ordered by a judge to cover St. Luke's legal costs from a 2013 federal antitrust lawsuit. "St. Luke's legal costs may total more than $25 million." For more

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Health care fraud charges and plea agreements filed against physician and two others
On January 5, 2016, U.S. Attorney's Office for the Middle District of Pennsylvania announced, "a criminal information has been filed in U.S. District Court in Scranton against Dr. John Terry, age 65, of Wellsboro, in connection with fraudulent prescriptions he wrote for Oxycodone, a Schedule II controlled substance.

"According to U.S. Attorney Peter Smith, in April 2013, Dr. Terry allegedly caused Medicare to be billed for fraudulent prescriptions intended for Stephen Heffner, Jr., age 46, of Elkland, knowing that Heffner was not his patient and that the Oxycodone was not actually intended for Heffner but for Dr. Terry's patient, David Hatch, age 28, of Addison, New York. Medicare paid for the prescription received by Heffner but actually delivered to Hatch." For more

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Research: Not nearly as transparent as it needs to be
On January 6, 2016, To Your Health reported, "Data manipulation, whether it occurs in the form of skewed voter registration, gerrymandering or outright ballot fraud, is unfortunately a practice with which we are all too familiar.

"But scientific data Let's start with these two glaring examples from the past decade or so:
Reports released by the General Accounting Office on March 4, 2002, indicated that a Pentagon agency, two major military contractors and an independent research team led by MIT researchers produced flawed studies which exaggerated the success of a key test used to justify spending billions of dollars on a fledgling national missile defense program." For more

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Owner of three Los Angeles clinics sentenced to 78 months in prison for Medicare fraud
On January 4, 2016, Assistant Attorney General Leslie R. Caldwell of the Justice Department's Criminal Division announced, "The former owner and operator of three medical clinics located in Los Angeles was sentenced today to 78 months in prison for his role in a scheme that submitted more than $4.5 million in fraudulent claims to Medicare."

According to the government press release, "Hovik Simitian, 48, of Los Angeles, pleaded guilty to one count of conspiracy to commit health care fraud on Aug. 18, 2015, and was sentenced today by U.S. District Court Judge Beverly Reid O'Connell of the Central District of California, who also ordered Simitian to pay $1,668,559 in restitution to Medicare.

"Simitian owned and operated Columbia Medical Group Inc., Life Care Medical Clinic and Safe Health Medical Clinic, three medical clinics in Los Angeles. In connection with his guilty plea, Simitian admitted that from approximately February 2010 through June 2014, he and his co-conspirators paid illegal cash kickbacks to patient recruiters who brought Medicare beneficiaries to the clinics." For more

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San Diego genetics laboratory pays $4 million to settle federal kickback allegations in connection with patient referrals
On December 30, 2015, U.S. Attorney for the Southern District of California Laura E. Duffy announced, "A San Diego-based medical diagnostic laboratory, Pathway Genomics Corporation, has paid $4,036,622.74 in a civil settlement to resolve allegations that it violated the False Claims Act by paying improper kickbacks to physicians and physician groups in exchange for patient referrals."

According to the government press release, "The settlement resolves allegations that Pathway induced health care providers to refer Pathway genetic testing kits and services, and then received government reimbursement for those tests in violation of the law. As alleged, Pathway offered physicians and medical groups reimbursements of up to $20 for each saliva kit they collected and submitted to Pathway for testing. The United States alleges that individual physicians received as much as $13,534 in reimbursements from Pathway and that most of the physicians had never ordered these costly genetic tests before enrolling in Pathway's reimbursement program. It is further alleged that, as its referrals increased, Pathway billed the high costs of these laboratory analyses to federal health care programs such as Medicare and TRICARE. Pathway has since voluntarily discontinued its physician reimbursement program." For more

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CVS among hundreds of providers violating HIPAA, review finds
On December 29, 2015, The Boston Globe reported, "When CVS Health customers complained to the company about privacy violations, some of the calls and letters made their way to Joseph Fenity. One patient's medication was delivered to his neighbor, revealing he had cancer. Another was upset because a pharmacist had yelled personal information across the counter.

"Fenity worked on a small team at CVS Health that dealt with complaints directed to the company president's office, assuring customers their situations were rare. 'I sincerely apologize on behalf of CVS Health,' Fenity says he'd respond. 'This is not how we handle things. The breach of your protected health information was an isolated incident and we'll do better.'" For more

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Government health care fraud recoveries slide
On December 28, 2015, Crain's Chicago Business reported, "The U.S. Justice Department is reporting it recovered the lowest amount of money from healthcare fraud cases in any year since 2009, according to new government data.

"The decline is largely due to the absence of major drug industry settlements, and doesn't reflect an easing of DOJ scrutiny of healthcare fraud, experts say." For more

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Government settles alleged False Claims Act violations with Memorial Health, Inc.
On December 23, 2015, U.S. Attorney for the Southern District of Georgia Edward J. Tarver announced, "Memorial Health, Inc., Memorial Health University Medical Center, Inc., Provident Health Services, Inc., and MPPG, Inc. d/b/a Memorial Health University Physicians have agreed to pay $9,895,043.04 to resolve allegations that they violated the False Claims Act by submitting claims to the Government in violation of the Stark Law. The settlement is the largest civil health care fraud recovery in the history of the United States Attorney's Office." For more

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U.S. settles with Aria Health Systems over unnecessary invasive procedures and improper compensation claims
On December 23, 2015, U.S. Attorney for the Eastern District of Pennsylvania
Announced, "The United States and Aria Health Systems, Inc. (Aria) today settled two False Claims Act matters which Aria self-disclosed. Aria agreed to pay $564,700 to resolve claims that a cardiologist performed unnecessary invasive procedures on inpatients and outpatients at their Torresdale Campus between October 1, 2012 and April 15, 2013. Aria also agreed to pay $2.5 million to resolve alleged violations of the False Claims Act regarding compensation to physicians that were in excess of fair market value. The settlement resolves claims regarding compensation paid to a cardiac thoracic surgeon from 2012 to 2014 and claims regarding the purchase of a trademark name in the course of the acquisition of an orthopedic group by Aria in December 2012. Aria is a major health care provider in Northeast Philadelphia and lower Bucks County." For more

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Clinical director of home care agency sentenced in Medicare fraud scheme
On December 22, 2015, U.S. Attorney's Office for Massachusetts announced, "The clinical director of a home nursing agency was sentenced yesterday in U.S. District Court in Boston in connection with her role in a multi-million dollar scheme to defraud Medicare.

"Janie Troisi, 66, of Revere, was sentenced by U.S. District Court Judge Douglas P. Woodlock to three years in prison and three years of supervised release. In August 2015, Troisi was convicted following a five-day trial of conspiracy to commit health care fraud and 10 counts of health care fraud.

"Troisi, a registered nurse, was the Clinical Director of At Home VNA (AHVNA), a home health agency located in Waltham, which was owned and operated by her co-conspirator, Michael Galatis, also a registered nurse. From 2009 to 2012, Troisi conspired with Galatis to submit more than $3.5 million in fraudulent home health care claims to Medicare." For more

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Coloplast Corp. and Liberator Medical agree to pay $3.6 million to resolve kickback allegations
On December 22, 2015, U.S. Attorney for Massachusetts Carmen Ortiz announced, " Coloplast Corp., a manufacturer of ostomy and continence care products, and Liberator Medical Supply, Inc., a medical products supplier, have agreed to pay $3,160,000 and $500,000, respectively, to resolve allegations that Coloplast paid unlawful kickbacks to several medical suppliers, including Liberator, to induce them to conduct promotional campaigns designed to refer individual users to Coloplast products."

According to the government press release, "The settlement with Coloplast resolves allegations that it paid kickbacks to Byram Healthcare Centers, Inc.; CCS Medical, Inc.; Liberator; Liberty Medical, Inc.; and Handi Medical, Inc. in return for marketing promotions and conversion campaigns. In the case of Byram, Liberty, and Handi, Coloplast's promotional campaigns allegedly included kickbacks in the form of funding for cash incentives - sometimes known as "spiffs" - paid to the suppliers' sales personnel to induce them to refer patients to Coloplast products. In other instances, Coloplast allegedly gave rebates or price concessions as inducements for the promotional campaigns.

"The settlement with Liberator resolves allegations that Liberator received kickbacks from Coloplast, in the form of price concessions, in return for Liberator's agreement to conduct two campaigns promoting Coloplast ostomy products to Liberator's customers." For more

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SCCE Blog Posts

Compliance fiction
Let me tell you a completely fabricated compliance story. A company of 250 employees had a compliance and ethics program. They had brought in independent experts and anonymously surveyed all the employees. The survey revealed that every employee felt free to share issues with their supervisor, HR, compliance officer and CEO. Anything any employee felt they needed to report was reported without any concern. They felt good about the follow-up."The culture was one of the finest in the world."But there was a problem. For more

Time management: Fifty bucks worth
Organizations are finalizing their strategies for the upcoming year. Ethics and Compliance Officers are updating their programs. Individuals are updating their personal and career goals and some are creating resolutions. One topic worth evaluation is time management. For more

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This Week’s Links:

FierceHealthFinance: "2016: More antitrust actions, Medicare expansion tussles likely" For more

The Huffington Post: "Commonly Encountered Federal Business Fraud Statutes" For more

South Florida Business Journal: "5 news-making cases of alleged health care fraud from 2015" For more

GAO: DOD And VA Health Care: Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.
GAO-16-158, January 5. For more

OIG Advisory Opinions:
- Advisory Opinion 15-17 For more

- Advisory Opinion 15-16 For more

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This week, MediRegs provided TWCC readers with the following: From the GAO, CMS Transmittals and From the OIG.

Regulatory News

CMS Update

Dates & Times of Upcoming National Provider Calls
Registration is now open for the following CMS Calls:

Tuesday, January 19, 2016; 2:00 - 3:30 PM ET - ESRD QIP: Payment Year 2019 Final Rule Call

Wednesday, January 20, 2016; 2:30 - 4:00 PM ET - Collecting Data on Global Surgery as Required by MACRA Listening Session

Thursday, February 4, 2016; 1:30 - 3 PM ET - IMPACT Act: Connecting Post-Acute Care across the Care Continuum Call

To register and receive call-in information, you must register for calls on the CMS Upcoming National Provider Calls registration website. Space may be limited, register early. Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.

The presentation for calls will be posted on the FFS National Provider Calls web page. A link to the slide presentation will be emailed to all registrants on the day of the call.

Visit the Continuing Education Credit Notification web page for continuing education information.

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In the Federal Register

Final rule, correction: Medicare Program; End-Stage Renal Disease Prospective Payment System, and Quality Incentive Program; Correction
As stated by CMS:
"This document corrects technical and typographical errors that appeared in the final rule published in the Federal Register on November 6, 2015, entitled "Medicare Program; End-Stage Renal Disease Prospective Payment System, and Quality Incentive Program.'" For more

Final rule: Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
As stated by CMS:
"This final rule establishes a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment." For more

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CMS Transmittals

2015 Transmittals and MLN Matters For more

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Acronym Library

Click here for more from CMS Acronyms

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Your HCCA Office is located at:
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Email: service@hcca-info.org
Contact: Margaret Dragon, Editor, This Week in Corporate Compliance: 952-405-7937

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