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October 11 – 13, 2015
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October 25-28, 2015
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This Week’s Headlines – March 27, 2015

SCCE and HCCA combined membership reaches 15,000

Federal jury finds husband and wife guilty of operating a clinic to defraud Medicare

Doctor sentenced to nine months in prison for taking cash kickbacks on patient referrals, failing to report nearly $1 million in income

Supreme Court separates facts from opinion in Omnicare ruling

U.S. Attorney and HHS ensure effective communication with the hearing impaired at St. Francis Hospital

Michigan physician pleads guilty for role in $3.6 million Medicare fraud scheme

Los Angeles medical supply company owner convicted in $3.3 million Medicare fraud scheme

Medical equipment supply company owner convicted for $3.5 million Medicare and Medi-Cal fraud scheme

Owner and executives convicted in Medicare referral kickback conspiracy at closed Sacred Heart Hospital

Cardiac monitoring company to pay $6.4 million for alleged overbilling of government health care programs

Speech therapist faces 10 years for $3.7M in bogus claims

This Week’s Links

Regulatory News

CMS Update

From the GAO

In the Federal Register

CMS Transmittals

From the OIG

Acronym Library


Headlines

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SCCE and HCCA combined membership reaches 15,000
On March 24, 2015, the Society of Corporate Compliance and Ethics (SCCE) and the Health Care Compliance Association (HCCA) announced an important milestone—the membership of the two associations combined “have increased to a total of 15,000 individuals.

“‘The growth of the SCCE and HCCA speaks to the increasing commitment to compliance by companies from across industry, and the value that they see in compliance programs. Business recognizes that compliance is not a part-time position or a role within another department, but a profession all its own,’ said SCCE and HCCA Chief Executive Officer Roy Snell.” For more

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Federal jury finds husband and wife guilty of operating a clinic to defraud Medicare
On March 25, 2015, the U.S. Attorney’s Office for the Middle District of Florida announced, “According to evidence presented during the seven-day trial, Gladys and Mario Fuertes established and operated a sham clinic, Gables Medical and Therapy Center, for the purpose of committing health care fraud. They employed unlicensed medical professionals and misused the Medicare billing numbers of other medical professionals, without their knowledge, in order to claim that they had rendered medical treatment to Gables patients. The Fuerteses also paid a co-conspirator to recruit Medicare beneficiaries for Gables, and to drive patients to the clinic for basic and sham medical services.

“Once recruited, Gladys and Mario Fuertes urged the Gables patients to enroll in Universal’s Medicare Part C and Part D plans. They believed that Universal paid a relatively high percentage of its claims. The Fuerteses fraudulently billed Universal and caused Universal’s Medicare Part C plan to be billed for Gables patients’ supposed treatments. The treatments included expensive HIV-related treatments that patients never actually received. Gladys and Mario Fuertes also billed Universal and caused Universal to be billed for services that required a physician’s presence when no licensed physician was present or rendered the service. The Fuerteses billed Universal in excess of $900,000.” For more

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Doctor sentenced to nine months in prison for taking cash kickbacks on patient referrals, failing to report nearly $1 million in income
On March 24, 2015, U.S. Attorney for the District of New Jersey Paul J. Fishman announced, “A doctor practicing family medicine in East Orange, New Jersey, was sentenced today to nine months in prison for receiving cash kickbacks for diagnostic testing referrals and failing to file tax returns on almost $1 million in income over a three-year period.

“Yash Khanna, 73, of Livingston, New Jersey, previously pleaded guilty before U.S. District Judge Claire C. Cecchi to a six-count superseding indictment charging him with conspiracy to violate the federal health care anti-kickback statute; soliciting and receiving more than $10,000 in illegal cash kickbacks for patient referrals in violation of the anti-kickback statute; and failing to file tax returns for tax years 2008, 2009 and 2010. Judge Cecchi imposed the sentence today in Newark federal court.” For more

Philadelphia Regional Conference
June 5, 2015
Philadelphia, PA


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Compliance Academies

June Basic Compliance Academy
June 8 – 11, 2015
Scottsdale, AZ


August Basic Compliance Academy
August 10 – 13, 2015
New York, NY


September Basic Compliance Academy
September 14 – 17, 2015
Chicago, IL


September Basic Compliance Academy
Sept 28 – Oct 1, 2015
Scottsdale, AZ


October Basic Compliance Academy
October 19 – 22, 2015
Las Vegas, NV

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Supreme Court separates facts from opinion in Omnicare ruling
On March 24, 2015, the Los Angeles Times reported, “The Supreme Court gave public companies slightly broader leeway in making public statements that turn out to be wrong, siding with a healthcare company over statements made — or omitted — in stock offering documents. In a unanimous ruling, the court said that Omnicare Inc. was not liable because the statements in dispute were opinions, and investors were unable to demonstrate that the Cincinnati pharmaceuticals services company knew they were false when it made them.” For more

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U.S. Attorney and HHS ensure effective communication with the hearing impaired at St. Francis Hospital
On March 23, 2015, U.S. Attorney’s Office for the District of Connecticut announced, “The U.S. Attorney’s Office for the District of Connecticut and the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), have entered into a voluntary resolution agreement with St. Francis Hospital and Medical Center in Hartford to ensure effective communication with and enhance the quality of services for persons who are deaf or hard of hearing.

“The matter was initiated by a complaint filed with the Department of Justice (DOJ) alleging violations of Title III of the Americans with Disabilities Act (ADA). Specifically, the complainant alleged that St. Francis Hospital and Medical Center (St. Francis Hospital) failed to provide auxiliary aids and services when necessary to ensure effective communication with him during multiple admissions to St. Francis Hospital. Title III of the ADA prohibits public accommodations, including hospitals, from discriminating on the basis of disability in the full and equal enjoyment of their goods, services, facilities, privileges, advantages or accommodations.” For more

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Michigan physician pleads guilty for role in $3.6 million Medicare fraud scheme
On March 23, 2015, Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division announced, “Kutub Mesiwala, 64, of Bloomfield Hills, Michigan, pleaded guilty before U.S. District Judge George Caram Steeh of the Eastern District of Michigan to one count of conspiracy to commit health care fraud. A sentencing hearing is set for Oct. 5, 2015.

“According to admissions in his plea agreement, Mesiwala referred patients to Detroit-area home health agency Advance Home Health Care Services Inc. (Advance) and other home health care agencies in exchange for cash kickbacks. Advance’s owner, Amer Ehsan, pleaded guilty on July 24, 2014, to fraudulently billing Medicare for $3.6 million in home health services that were not medically necessary or not provided through Advance. Ehsan is awaiting sentencing.

“Mesiwala admitted that Medicare paid a total of $770,668.31 to Advance and $118,375.81 to other home health care companies for fraudulent claims based on his referrals.” For more

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Los Angeles medical supply company owner convicted in $3.3 million Medicare fraud scheme
On March 20, 2015, Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division announced, “Hakop Gambaryan, 55, of East Hollywood, the owner of Colonial Medical Supply, was convicted of four counts of health care fraud. A sentencing hearing will take place before U.S. District Judge Otis D. Wright II of the Central District of California, and will be scheduled at a later date.

“According to evidence presented at trial, between March 2006 and December 2012, Gambaryan paid cash kickbacks to medical clinics for fraudulent prescriptions for durable medical equipment, such as expensive power wheelchairs, which the patients did not need. Gambaryan then used these prescriptions to bill Medicare for the unnecessary power wheelchairs and other equipment.

“At trial, the evidence established that Gambaryan personally delivered power wheelchairs to many beneficiaries who were able to walk without assistance. In one instance, Gambaryan carried a power wheelchair up a flight of stairs for a woman who lived in a second floor apartment with no elevator. In another instance, the power wheelchair would not fit inside the beneficiary’s home so Gambaryan put it in the beneficiary’s garage.” For more

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Medical equipment supply company owner convicted for $3.5 million Medicare and Medi-Cal fraud scheme
On March 20, 2015, the U.S. Department of Justice announced, “A jury in federal court in Los Angeles convicted the former owner of a durable medical equipment supply company of health care fraud charges in connection with a $3.5 million Medicare and Medi-Cal fraud scheme.”

According to the government press release, “Sylvia Walter-Eze, 48, of Stevenson Ranch, California, was convicted of one count of conspiracy to commit health care fraud, four counts of health care fraud, and one count of conspiracy to pay and receive illegal kickbacks. Sentencing is scheduled for June 15, 2015, before U.S. District Judge R. Gary Klausner of the Central District of California.

“The evidence at trial demonstrated that Walter-Eze, the then-owner of Ezcor Medical Supply, paid illegal kickbacks to patient recruiters in exchange for patient referrals. The evidence further showed that Walter-Eze paid kickbacks to physicians for fraudulent prescriptions, primarily for medically unnecessary—but expensive—power wheelchairs, that she then used to support her fraudulent bills to Medicare and Medi-Cal.” For more

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Owner and executives convicted in Medicare referral kickback conspiracy at closed Sacred Heart Hospital
On March 19, 2015, the U.S. Attorney’s Office for the Northern District of Illinois announced, “The former owner and chief executive officer, the chief operating officer, and the chief financial officer of the now-closed Sacred Heart Hospital were convicted by a jury after a nearly two-month trial of collectively paying hundreds of thousands of dollars in illegal kickbacks in exchange for the referral of hospital patients who were insured by Medicare and Medicaid. The jury found that Edward J. Novak, 60, of Park Ridge, Sacred Heart’s owner and chief executive officer, Roy M. Payawal, 66, of Burr Ridge, executive vice president and chief financial officer, and Clarence Nagelvoort, 59, of Chicago, paid physicians concealed bribes and kickbacks to induce patient referrals and to increase the patient census, which, in turn, increased hospital revenue.

“Sacred Heart Hospital was a 119-bed acute care facility located at 3240 West Franklin Blvd., in Chicago. The hospital closed and filed for bankruptcy in 2013, after Medicare payments were suspended in the aftermath of criminal charges that were first filed in April 2013.” For more

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Cardiac monitoring company to pay $6.4 million for alleged overbilling of government health care programs
On March 19, 2015, the U.S. Department of Justice announced, “BioTelemetry Inc., a heart monitoring company headquartered in Malvern, Pennsylvania, has agreed to pay $6.4 million to resolve allegations made under the False Claims Act (FCA) that its subsidiary, CardioNet, overbilled Medicare and other federal health programs for Mobile Cardiac Outpatient Telemetry (MCOT) services when those services were not reasonable or medically necessary.”

On March 26, 2015, StreetInsider.com reported, “The settlement relates to allegations that BioTelemetry encouraged physicians to use two non-specified diagnosis codes to ensure coverage of mobile cardiac telemetry between November 2008 and June 2011.” For more | DOJ

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Speech therapist faces 10 years for $3.7M in bogus claims
On March 24, 2015, McKnight’s Long-Term Care News reported, “A 44-year-old licensed speech therapist faces 10 years in prison and a $250,000 fine after admitting she and a colleague submitted $3.7 million in fraudulent insurance claims for services either unnecessary or not provided at all. It serves as another stark reminder that providers need to know how their contractors are conducting business.” For more

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This Week’s Links:

AdvertisingAge: “Sophisticated Health Data Industry Needs Self-Reflection” For more

Maryland Reporter: “Senate broadens protections for those reporting fraud” For more

OIG: 
-Advisory Opinion 15-04 For more

-Testimony of Gary Cantrell, Deputy Inspector General for Investigations, Office of Investigations, Office of Inspector General, U.S. Department of Health and Human Services before the House Committee on Ways and Means Subcommittee on Oversight: Fraud in Medicare For more

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MediRegs is a pioneer in Ethics, Compliance and Regulatory Information Management. With more than 500 organizations using MediRegs already, you can confidently empower your team with our ADVantage ArchitectureSM.This week, MediRegs provided TWCC readers with the following: From the GAO, In the Federal Register, 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, April 7, 1:30 pm - Medicare Shared Savings Program ACO: Preparing to Apply for 2016

Wednesday, April 15, 2-3:30 pm  - Open Payments (Sunshine Act) 2015: Prepare to Review Reported Data

Thursday, April 16, 1:30 PM - How to Register for the PQRS Group Practice Reporting Option in 2015

Tuesday, April 21, 1:30 pm - Medicare Shared Savings Program ACO: Application Process

Tuesday, June 16 from 1:30-3 pm ET - National Partnership to Improve Dementia Care in Nursing Homes and QAPI

  • Thursday, September 3 from 1:30-3 pm ET
  • Tuesday, December 1 from 1:30-3 pm ET

To register- To 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

Upcoming Webinar
Tuesday, March 31; 2-4pm ET - Medicare Basics for New Providers Webinar
Registration:

  • To register
  • This webinar will offer both continuing education units (CEU) and continuing medical education (CME) credit

HCCA’s 23-minute video and trainer’s guide provides everything you need to conduct training for new employee orientations and staff refreshers.
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Web Conferences

Internal Compliance Surveys: Measuring Your Departments Effectiveness
March 30


The OIG is looking behind the Corporate Veil. Beware Excluded Owners/Managers
April 2, 2015


Hot Topics in Laboratory Compliance
April 8, 2015


Breach Risk Assessments Using Real Examples
April 9, 2015


Remote Monitoring: An Institutional Journey
April 16, 2015


OCR HIPAA Audit Program 2015 and Beyond - What We Know So Far
April 27, 2015


Is anything secure? (Compliance with Information Security Requirements in the Healthcare Industry)
April 29, 2015

Upcoming Webinar
Tuesday, March 31; 2-4pm ET - Medicare Basics for New Providers Webinar
Registration:

  • To register
  • This webinar will offer both continuing education units (CEU) and continuing medical education (CME) credit

Wednesday, April 1; 3-4:30pm ET – Webinar for Comparative Billing Report on Modifier 25: Nurse Practitioners
How to Register and Event Replay

Electronic Health Record Incentive Programs and 2015 Edition Health IT Certification Criteria rules proposed
On March 20, HHS, CMS, and the Office of the National Coordinator for Health Information Technology (ONC) announced the release of the Stage 3 notice of proposed rulemaking for the Medicare and Medicaid Electronic Health Records (EHRs) Incentive Programs and 2015 Edition Health IT Certification Criteria to improve the way electronic health information is shared and ultimately improve the way care is delivered and experienced. Together, these proposed rules will give providers additional flexibility, make the program simpler, drive interoperability among electronic health records, and increase the focus on patient outcomes to improve care.

The Meaningful Use Stage 3 proposed rule issued by CMS specifies new criteria that eligible professionals, eligible hospitals, and Critical Access Hospitals (CAHs) must meet to qualify for Medicaid EHR incentive payments. The rule also proposes criteria that providers must meet to avoid Medicare payment adjustments based on program performance beginning in payment year 2018. The rule gives more flexibility and simplifies requirements for providers by focusing on advanced use of electronic health records and eliminating requirements that are no longer relevant.

The 2015 Edition Health IT Certification Criteria proposed rule aligns with the path toward interoperability – the secure, efficient, and effective sharing and use of health information. The proposed rule builds on past editions of adopted health IT certification criteria, and includes new and updated IT functionality and provisions that support the EHR Incentive Programs care improvement, cost reduction, and patient safety across the health system.
For more:

Full text of this excerpted HHS press release (March 20).

New from MLN
“Safeguard Your Identity and Privacy Using PECOS” Fact Sheet — Reminder

Internet-based PECOS FAQs” Fact Sheet — Reminder

 

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Transforming Your RAC Program: It Happens Through Centralization
May 5, 2015


Security Incident Response - Spend a little now and save a lot later
May 6, 2015


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Vol. XVII, No. 12 |
March 27, 2015

Health Care Compliance Association

Copyright © 2015 Health Care Compliance Association

From the GAO

  • Medicaid Financing: States' Increased Reliance on Funds from Health Care Providers and Local Governments Warrants Improved CMS Data Collection [Reissued on March 13, 2015] GAO-14-627: Published: Jul 29, 2014. Publicly Released: Jul 29, 2014 (PDF) For more
  • Medicaid Financing: Questionnaire Data on States' Methods for Financing Medicaid Payments from 2008 through 2012 (GAO-15-227SP, March 2015), an E-supplement to GAO-14-627 GAO-15-227SP: Published: Mar 13, 2015. Publicly Released: Mar 13, 2015 (HTML) For more

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In the Federal Register
Final rule; correcting amendment: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015; Corrections

As stated by CMS:
"This document corrects technical errors that appeared in the final rule with comment period published in the November 13, 2014 Federal Register (79 FR 67547-68092) entitled, "Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015." The effective date for the rule was January 1, 2015." For more

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CMS Transmittals

  • 2015 Transmittals and MLN Matters For more   

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From the OIG
Audit Report
Medicare Compliance Review of Northwestern Memorial Hospital for 2011 and 2012 (A-05-13-00051) (03/03/2015) (PDF) For more

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Acronym Library

MECT Multiple Electroconvulsive Therapy
MED Medicare Enrollment Data (System)
MED Medicare Exclusion Database

Click here for more from CMS Acronyms

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HCCA’s website gives members and visitors secure, online access to register for conferences, order products, join HCCA, update membership information, post and follow discussions on HCCAnet, the premier social network for compliance professionals, and search compliance news and resources, and much more. Visit www.hcca-info.org to check out HCCA’s full array of online services.

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HCCA Headquarters Contact Information
Your HCCA Office is located at:
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Minneapolis, MN 55435
HCCA Phone: 888-580-8373
Fax: 952-988-0146
Minnesota Phone: 952-988-0141
Email: service@hcca-info.org
Contact: Margaret Dragon, Editor, This Week in Corporate Compliance: 781-593-4924

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This Week’s HCCA Corporate Members

MediTract

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