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Healthcare fraud case leads to 13-year sentence - Akorn accused of sending phony data to FDA on antibiotic - Connecticut drug rehab center Pays $1.3M - And More

Headlines

Healthcare fraud case leads to 13-year sentence

Akorn accused of sending phony data to FDA on antibiotic

Connecticut drug rehab center Pays $1.3M

Southern Texas patient recruiter convicted

Texas health care company shuts down amid fraud investigation

Two Maine men plead not guilty to federal health care fraud charges

Three Miami home health agency owners charged in fraud scheme

Two new healthcare fraud cases top $2 million in alleged illegal activity

Doctor convicted in U.S. of obstructing Warner Chilcott kickback probe

The False Claims Act in 2017: The year in review and what to watch in 2018

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News of Interest

Michigan Lawyers Weekly: “Government signals sea change on health care false claims” READ MORE

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Highlights from The Compliance & Ethics Blog

HHS Inspector General Dan Levinson shares the OIG’s latest perspectives [Podcast]

On April 16, 2018 Daniel R. Levinson, the Inspector General at the Department of Health and Human Services once again returned to the stage for the HCCA Compliance Institute.  As he has done so many times and so well, he provided the Institute attendees the latest in thinking from the Office of Inspector General. READ MORE

D is for due diligence

Due diligence.  It sounds so professional.  So significant.  It always made me feel that I could just toss it into a sentence and everyone would think I was smart and experienced in such weighty matters. READ MORE

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Headlines

Healthcare fraud case leads to 13-year sentence

On May 3, 2018, Roanoke-Chowan News-Herald reported, “A federal case involving healthcare fraud that cost a local nurse her livelihood last year landed a Greenville man in prison here Tuesday.

“United States Attorney Robert J. Higdon, Jr. announced in federal court that Shephard Lee Spruill, age 47, was sentenced to 96 months behind bars on the charge of healthcare fraud conspiracy, and 60 months in prison for perjury, to be served concurrently.” READ MORE

Akorn accused of sending phony data to FDA on antibiotic

On May 2, 2018, Bloomberg reported, “Akorn Inc. officials allegedly submitted phony data to regulators about an antibiotic drug, prompting Fresenius SE to pull out of a $4.3 billion buyout of the generic drugmaker.”

According to the report, “Akorn has argued Fresenius wrongfully pulled out of the $34-per-share deal because of buyer’s remorse -- not any findings that its officials had misled regulators about product-development practices.” READ MORE

Connecticut drug rehab center pays $1.3M

On May 2, 2018, Connecticut Law Tribune reported, “A Connecticut-based substance abuse treatment facility has agreed to pay $1.37 million to settle claims it defrauded the Medicaid program.

“The agreement by the Connecticut Attorney General’s Office and the U.S. Attorney’s Office of the District of Connecticut with New Era Rehabilitation Center would resolve allegations the business violated the state and federal False Claims Act.” READ MORE

Southern Texas patient recruiter convicted

On May 2, 2018, the U.S. Department of Justice announced, “A federal jury found Mercy O. Ainabe, a patient recruiter for Texas Tender Care, guilty today for her role in a $3.6 million Medicare fraud scheme involving fraudulent claims for home health services.”

According to the government press release, “After a three-day trial, Mercy O. Ainabe, 52, of Houston, Texas, was convicted of one count of conspiracy to commit health care fraud, five counts of health care fraud, and one count of conspiracy to pay health care kickbacks.” READ MORE

Texas health care company shuts down amid fraud investigation

On May 1, 2018, KRISTV reported, “Employees who worked for a local home health care company no longer have jobs.

“Merida Health Care Group closed its Corona Drive location last week after a slew of legal troubles linked to a fraud and money laundering investigation. It's unclear how many jobs are affected.” READ MORE

Two Maine men plead not guilty to federal health care fraud charges

On May 1, 2018, Portland Press Herald reported, “Two Maine men have been indicted on federal charges of defrauding the MaineCare health care program and with soliciting and receiving health care kickbacks over a roughly two-year period, federal prosecutors said. Both pleaded not guilty on Tuesday.

“The U.S. Attorney’s Office in Maine said a federal grand jury indicted Abdirashid Ahmed, 38, of Lewiston and Garat Osman, 32, of Auburn for allegedly getting kickbacks of up to $200 per referral of people to a specific health care provider.” READ MORE

Three Miami home health agency owners charged in fraud scheme

On April 30, 2018, Home Health Care News reported, “Ailin Consuelo Rodriguez Sigler, 39; Ziola C. Rios, 57; and Thomas A. Rodriguez, 66, were charged in the indictment with one count of conspiracy to commit health care fraud and wire fraud, and three counts of health care fraud. The three operated Florida Patient Care Corp.” READ MORE

Two new healthcare fraud cases top $2 million in alleged illegal activity

On April 30, 2018, Healthcare Finance reported, “Add two more healthcare fraud cases to the ever-expanding list. 

“In the first, Las Vegas medical practice Cardiovascular and Thoracic Surgeons of Nevada will pay $1.5 million to settle allegations that they violated the False Claims Act through illegal billing…”

According to the report, “The second case is from suburban Illinois. A physician has been indicted on federal fraud charges for allegedly pocketing nearly $1 million in Medicare and private insurer payments for services that never happened.” READ MORE

Doctor convicted in U.S. of obstructing Warner Chilcott kickback probe

On April 30, 2018, Reuters reported, “A Massachusetts doctor was convicted on Monday of obstructing an investigation into kickbacks paid by the drugmaker Warner Chilcott and of wrongly giving one of its sales representatives access to her patients' information.”
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The False Claims Act in 2017: The year in review and what to watch in 2018

On April 25, 2018, Bloomberg BNA reported, “In 2017, the Department of Justice (the ‘DOJ’) continued its robust enforcement of the FCA. In fiscal year 2017, the DOJ obtained $3.7 billion in settlements and judgments in FCA cases. While the government’s total recovery dipped slightly from 2016, 2017 was the eighth straight year that recoveries topped $3 billion.” READ MORE

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Regulatory News

CMS Update

New strategy to fuel data-driven patient care, transparency
On April 26, CMS Administrator Seema Verma announced the agency’s new Data Driven Patient Care Strategy as part of the MyHealthEData initiative. The strategy positions CMS to further support industry innovation in unleashing the power of data to inform patients’ healthcare decisions and transform the healthcare system by enhancing security and privacy, improving quality, increasing efficiency, and reducing costs.
For More Information:

Provider Compliance
Provider compliance tips for ordering lower limb orthoses

The Medicare Fee-For-Service (FFS) improper payment rate for lower limb orthoses was 66.7 percent, representing a projected improper payment amount of $319.6 million. The 2017 reporting period indicates the following reasons for improper payments for lower limb orthoses:

  • Insufficient documentation errors - 92.2 percent
  • No documentation - 2.1 percent
  • Medical necessity - 1.5 percent

Prevent denials by reviewing the Provider Compliance Tips for Ordering Lower Limb Orthoses  Fact Sheet, which details Medicare’s coverage and documentation requirements.
Additional Resources:

For the 2 Local Coverage links below please scroll to the bottom of the page, hit accept, then the LCD page will appear.

New from MLN

Revisions to the Telehealth Billing Requirements for Distant Site Services — New READ MORE

Acute Care Hospital IPPS Booklet — Revised
READ MORE

Enhancements to Processing of Hospice Routine Home Care Payments — New READ MORE

Comprehensive ESRD Care Model Telehealth - Implementation — New READ MORE

New Physician Specialty Code for Medical Genetics and Genomics — New READ MORE

Processing Instructions to Update the Identification Code Qualifier Being Used in the NM108 Data Element — New READ MORE

In the Federal Register

FR Index 2018 READ MORE

CMS Transmittals

2018: READ MORE

From the OIG

Updated Provider Self-Disclosure Settlements READ MORE

This is Real: Go Undercover with the OIG’s New Podcast
In 2014, more than 30 people were arrested in the nation's capital on charges related to health care fraud. This series follows HHS OIG special agents as they work to uncover the complex fraud schemes, expose the greed of those involved, and bring the criminals to justice. And all of this is real! READ MORE

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Acronym Library

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Health Care Compliance Library
HCCA offers members and registered guests access to an extensive library of articles. Information provided covers topics in corporate compliance and ethics in healthcare organizations. Contributing authors include attorneys, chief compliance officers, providers of auditing, monitoring, coding, billing and technology services, and other members of our compliance community.