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The pill mill doctor who prescribed thousands of opioids and billed dead patients - Final defendants in multi-million dollar health care fraud and money laundering case sentenced to federal prison terms - Kindred pays feds largest penalty ever recorded for integrity agreement violations -And More

Headlines

The pill mill doctor who prescribed thousands of opioids and billed dead patients

Final defendants in multi-million dollar health care fraud and money laundering case sentenced to federal prison terms

Kindred pays feds largest penalty ever recorded for integrity agreement violations

Mylan investigations mount as West Virginia opens fraud probe

Skilled-nursing facility operator, execs pay $30M over improper Medicare, Tricare billing

Former owner of Lake Whitney Medical resentenced

Audit says home health care companies overbilled Mass. Medicaid by $23m

OSHA issues new guidance on settlement approval in whistleblower cases

UConn Health pays over $180k in settlement for overbilling allegations

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News of Interest

The Hill: “Health Care Fraud: Criminal Prosecution Necessary But Not Sufficient” READ MORE

The New York Times: “Wells Fargo settlement raises questions on disclosure” READ MORE

DOJ: Assistant Attorney General Leslie R. Caldwell Delivers Remarks at New York University Center for Cybersecurity READ MORE

OIG: Video Series Eye on Oversight: Provider Self-Disclosure Protocol READ MORE

OIG: Proposed Rule: State Medicaid Fraud Control Units READ MORE

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Insights from the SCCE/HCCA Blog

Undermining corporate self-policing
Those of us in the compliance and ethics field are believers.  We believe companies should have effective compliance and ethics programs to fight all kinds of corporate crime and misconduct... But there is a nasty little secret behind this conclusion.  The legal system, which is supposed to help prevent business crime, actually undermines company compliance efforts in some very serious ways. READ MORE

Patient privacy and drug diversion by healthcare personnel
When personnel divert controlled substances within healthcare facilities, it is vital to consider the potential for patient harm. We often think of harm in terms of physical injury, but there is one type of patient harm we often don’t consider, namely patient privacy. READ MORE

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Headlines

The pill mill doctor who prescribed thousands of opioids and billed dead patients

On September 22, 2016, The Washington Post reported, “A former Michigan doctor who ran a pill mill for 16 months, distributing tens of thousands of narcotics and controlled substances to people who didn't need them for medical purposes, has agreed to pay $200,000 to settle a federal lawsuit that accused him of, among other things, falsifying records to charge dead patients, subjecting patients to unnecessary tests and billing for office visits that never happened.

“The settlement was announced Wednesday, amid National Heroin and Opioid Awareness Week, and came nearly four years after Hussein Awada, 46, was accused of defrauding Medicare, Medicaid and Blue Cross Blue Shield of about $2.3 million. He was charged in December 2012 of unlawful distribution of a controlled substance and conspiring to commit health care fraud. Awada pleaded guilty and was sentenced last November to seven years in federal prison.” READ MORE | DOJ

Final defendants in multi-million dollar health care fraud and money laundering case sentenced to federal prison terms

On September 21, 2016, the U.S. Attorney for the Central District of California Eileen M. Decker announced, “With the final defendant receiving a prison term yesterday, six defendants who participated in a multi-million dollar health care fraud scheme or helped launder the illicit proceeds have now been sentenced to federal prison.

“Edgar Pogosian, also known as 'Edgar Hakobyan,' 32, of Glendale, was sentenced yesterday to 18 months in prison. Pogosian was found guilty earlier this year of conspiring to commit money laundering and one count of money laundering.” READ MORE

Kindred pays feds largest penalty ever recorded for integrity agreement violations

On September 20, 2016, Modern Healthcare reported, “Kindred Healthcare will pay a $3 million penalty and close several sites after failing to implement corrections to its billing system under a corporate integrity agreement with the federal government. It's the largest such penalty issued to date.

“HHS' Office of Inspector General said Tuesday that the massive post-acute care provider failed to correct improper billing practices during the fourth year of its five-year corporate integrity agreement, stemming from a prior $25 million False Claims Act settlement with Gentiva Healthcare. Kindred acquired Gentiva in February 2015 in a $1.8 billion deal.”

According to the report, “Kindred had other False Claims Act troubles this year when, in January, a subsidiary paid a $125 million settlement over allegations that it knowingly caused contracted facilities to inappropriately bill Medicare. RehabCare allegedly set unrealistic financial goals for its contractors and scheduled patient therapy in order to maximize reimbursements, rather than considering what was best for the patient.” READ MORE | OIG

Mylan investigations mount as West Virginia opens fraud probe

On September 20, 2016, Bloomberg reported, “Mylan NV, already under fire from patients over the rising price of its EpiPen allergy shots, is facing a growing number of questions from lawmakers and law enforcement after the state of West Virginia launched a Medicaid fraud investigation into the drugmaker's pricing Tuesday.

“The inquiry, led by State Attorney General Patrick Morrisey, seeks to force Mylan to turn over company documents related to EpiPen. Similar requests have been made in the last month by lawmakers in Washington, and on Wednesday Mylan Chief Executive Officer Heather Bresch is to testify at a congressional hearing about the product’s price. The state attorneys general in Minnesota and New York also have inquiries, as do several congressional committees.” READ MORE

Skilled-nursing facility operator, execs pay $30M over improper Medicare, Tricare billing

On September 19, 2016, Modern Healthcare reported, “A skilled-nursing facility company and two of its executives will pay $30 million to settle allegations that they charged the government for medically unnecessary rehabilitation therapy services.

“The U.S. Justice Department alleged that North American Health Care sought payment from Medicare and Tricare for medically unnecessary services provided at its 35 skilled-nursing facilities from 2005 to 2011, a violation of the False Claims Act.

“Under the terms of the settlement, NAHC will pay $28.5 million, while board Chairman John Sorenson shells out $1 million and Senior Vice President of Reimbursement Analysis Margaret Gelvezon pays $500,000.” READ MORE | DOJ

Former owner of Lake Whitney Medical resentenced

On September 19, 2016, The Hillsboro Reporter reported, “The former owner of Lake Whitney Medical Center was resentenced to federal prison for health-care fraud and identity-theft violations in the Eastern District of Texas recently, according to U.S. Attorney John M. Bales.

“Tariq Mahmood, the 65-year-old Cedar Hill physician, was found guilty by a jury of conspiracy to commit health-care fraud, seven counts of health-care fraud and seven counts of aggravated identity theft following a four-day trial before U.S. District Judge Michael Schneider.” READ MORE | DOJ

Audit says home health care companies overbilled Mass. Medicaid by $23m

On September 18, 2016, The Boston Globe reported, “The state’s Medicaid program was routinely billed for home health care services that were never provided or were not medically necessary. Providers submitted documents with missing dates and signatures. Sometimes basic information like a patient’s medical history was nowhere to be found.

“These and other alleged violations were uncovered in an audit of nine agencies that do business with the state’s Medicaid program, called MassHealth — part of an effort by Governor Charlie Baker’s administration to rein in soaring spending on home health services.” READ MORE

OSHA issues new guidance on settlement approval in whistleblower cases

On September 15, 2016, the Occupational Safety and Health Administration (OSHA) announced in a press release, it had “published new guidelines for approving settlements between employers and employees in whistleblower cases to ensure that settlements do not contain terms that could be interpreted to restrict future whistleblowing. The guidelines, issued Sept. 9, make clear that OSHA will not approve a whistleblower settlement agreement that contains provisions that may discourage whistleblowing without outright prohibiting it.” READ MORE

UConn Health pays over $180k in settlement for overbilling allegations

On September 15, 2016, WTNH reported, “Deirdre M. Daly, United States Attorney for the District of Connecticut announced today that in a civil settlement agreement with the federal government, UConn Health will pay $184,984 to resolve allegations that it overbilled the Medicare Program.

“The government alleges that the University of Connecticut Health Center (UConn Health) improperly submitted claims to Medicare for certain wound closure procedures. The specific allegations are that UConn Health submitted claims using codes for higher paying wound closure procedures, rather than using codes for the lower paying wound closure procedures that were actually performed.” READ MORE | DOJ

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Regulatory News

Wolters Kluwer

CMS Update

Upcoming CMS Events

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

  • Wednesday, September 28, 2016; 1:30 – 3:00 PM ET - SNF Value-Based Purchasing Program
  • Wednesday, October 5, 2016; 1:30 - 3:00 PM ET - Emergency Preparedness Requirements
  • Thursday, October 13, 2016; 1:30 – 3:00 PM ET - IMPACT Act: Data Elements and Measure Development
  • Tuesday, November 1, 2016; 1:30 - 3:00 PM ET - How to Report Across 2016 Medicare Quality Programs

For details and to Register: READ MORE

For CEU information, visit the Continuing Education Credit Notification web page.

IRF and LTCH QRP Provider Preview Reports – Review your data by September 30
Inpatient Rehabilitation Facility (IRF) and Long-term Care Hospital (LTCH) Quality Reporting Program (QRP) Provider Preview Reports are available until September 30, 2016. Review your performance data on each quality measure prior to public display on the IRF Compare or LTCH Compare websites. For more information:

Corrections to the underlying data will not be permitted during this time. However, you can request a CMS review during the 30-day preview period if you believe the data is inaccurate.

Provider Compliance
Reporting changes in ownership
A 2016 Office of the Inspector General (OIG) report noted that providers may not be informing CMS of ownership changes. Providers must update their enrollment information to reflect changes in ownership within 30 days. Owners are individuals or corporations with a 5 percent or more ownership or controlling interest. Failure to comply could result in revocation of your Medicare billing privileges. Resources:

In the Federal Register

Rule: Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating.. 63859-64044 [2016-21404] READ MORE

OSHA
Rule: Procedures for the Handling of Retaliation Complaints Under the Employee Protection Provision of the.. 63396-63414 [2016-21758] READ MORE

CMS Transmittals

2016 Transmittals READ MORE

Program Integrity (PUB. 100-08)
Transmittal #676 Date: September 16, 2016 - Clarification of Certain Policies in Pub. 100-08, Chapter 15 Regarding the Processing of Form CMS-855R Applications (PDF) READ MORE

From the OIG

Audit Reports

  • A Kansas Physical Therapy Practice Claimed Unallowable Medicare Part B Reimbursement for Some Outpatient Physical Therapy Services (A-07-14-01146) (08/22/2016) (PDF)
    READ MORE
  • Kansas Correctly Invoiced Rebates to Manufacturers for Most Physician-Administered Drugs Dispensed to Enrollees of Medicaid Managed-Care Organizations (A-07-15-06060) (08/18/2016) (PDF)
    READ MORE  

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Acronym Library

MTMP

Medication Therapy Management Program

MTSO

Medical Transcription Service Organization

MTUS

Miles/Times/Units/Service

For more CMS Acronyms:
http://www.cms.hhs.gov/apps/acronyms/ 
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