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Brothers who ran seven-year health fraud scam face sentencing - Kansas hospital loses Medicare billing privileges, may be forced to close - Humana faces anti-kickback, False Claims Act suit over diabetes testing equipment - And More

Headlines

Brothers who ran seven-year health fraud scam face sentencing

Kansas hospital loses Medicare billing privileges, may be forced to close

Humana faces anti-kickback, False Claims Act suit over diabetes testing equipment

How two nursing home staffers uncovered a $230M Medicare fraud In Columbia, TN

Fifth board member quits Nashville General Hospital, citing 'grave concerns'

Another doctor pleads guilty in Montgomery pill mill investigation

New York suspends nurse for HIPAA violation affecting 3K patients

New Colorado law sets 30-day requirement for data breach notification

Court revives $35 million False Claims Act lawsuit against Brookdale

Grand jury indicts owner of local opioid treatment clinic

“No-poach” prosecutions in health care maybe (definitely are) coming

Alabama doctor gets five years in health care fraud case

Court documents reveal suspicions of fraud, theft at nursing home

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Highlights from The Compliance & Ethics Blog

Margaret Hambleton on five questions every executive should ask [Podcast]

At the 2018 HCCA Compliance Institute, Lloyd Dean, the CEO of Dignity Health wowed the crowd as he discussed his very positive perspective on compliance and the importance of compliance programs to the organization.

During his speech he shared five compliance-related questions that he always asks when evaluating a new business opportunity. Two things were intriguing about those questions. First, they had clearly been internalized within executive decision making. The compliance team didn’t have to ask them; management already did. Second, the questions were both simple and insightful, enabling management to quickly get a sense of whether there were potential risks that would require the compliance team’s help. READ MORE

J is for join together

For some reason “J” is turning out to be a tough letter to organize around.  I’m not sure why.  So I’ll ask for your help.  Maybe we can rewrite this together with your input and suggestions.  Here’s what I have been thinking about.

On a recent business trip to a small factory in the Mid-West United States, I was talking to one of the business leaders.  I commented on the chocolate brownies sitting on a table near the entrance to the facility.  He smiled and said “Every month, the folks here have a bake sale.  They bring in homemade baked goods and sell them.  All of the money is pooled and we donate it to a local children’s charity.” READ MORE

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Headlines

Brothers who ran seven-year health fraud scam face sentencing

On June 13, 2018, Associated Press reported, “Two brothers who ran a bribes-for-referrals health fraud scam that brought in more than $100 million over several years were due in court Wednesday to face sentencing, in a case that already has produced more than 50 guilty pleas or convictions.

“David and Scott Nicoll were arrested in 2013 and pleaded guilty to conspiracy and money laundering through their New Jersey company, Biodiagnostic Laboratory Services. Of more than 50 people who have pleaded guilty since then, more than three dozen were doctors who admitted taking bribes.” READ MORE

Kansas hospital loses Medicare billing privileges, may be forced to close

On June 12, 2018, Becker's Hospital CFO Report reported, “CMS terminated Overland Park, Kan.-based Blue Valley Hospital's Medicare contract in April, and the hospital faced another setback last week when a federal judge ruled she did not have jurisdiction to hear the hospital's case against HHS and CMS challenging the Medicare termination decision, according to KCUR.” READ MORE

Humana faces anti-kickback, False Claims Act suit over diabetes testing equipment

On June 12, 2018, Louisville Business First reported, “Humana Inc. will face an anti-kickback and False Claim Act lawsuit involving a deal it made with a division of international pharmaceutical giant Hoffman-La Roche Ltd.

“The U.S. District Court for the Northern District of Illinois tossed motions by Louisville-based Humana (NYSE: HUM) and Indianapolis-based Roche Diagnostics Corp. to dismiss a whistleblower case brought against the companies. The suit was brought by a now former Roche Diagnostics employee who, in part, alleges that Roche inappropriately dismissed debt Humana owed to Roche to keep Roche Diagnostic's diabetes testing products on Humana's formularies and to exclude competing products, according to copy of the court's decision.” READ MORE

How two nursing home staffers uncovered A $230M Medicare fraud In Columbia, TN

On June 12, 2018, Nashville Public Radio reported, “A nursing home chain with more than two dozen facilities in Tennessee has settled a $230 million Medicare fraud case.”

According to the report, “LeeAnn Holt and Kristi Emerson, both of whom are occupational therapists from Columbia, collected reams of anecdotes — in part, because they were concerned they might get in trouble themselves.  That evidence is the basis of settlement announced late Friday between the federal government and Louisville-based Signature Healthcare, which operates more than 100 facilities in 17 states.” READ MORE

Fifth board member quits Nashville General Hospital, citing 'grave concerns'

On June 11, 2018, The Tennessean reported, “Another member of Nashville General Hospital’s oversight board has resigned – the fifth in a month – this time citing a lack of transparency in how the board approved a new contract for the hospital CEO.

“Board Member Fredia Outlaw resigned from the Hospital Authority Board on Thursday, citing ‘grave concerns’ about the board, according to a resignation letter obtained by The Tennessean on Monday.” READ MORE

Another doctor pleads guilty in Montgomery pill mill investigation

On June 11, 2018, WSFA reported, “Another defendant in the ongoing federal investigation into a Montgomery pill mill has pleaded guilty.

“Dr. Willie Chester, 65, of Pike Road, pleaded guilty to one count of aiding and abetting the fraudulent acquisition of controlled substances, admitting that he wrote a prescription for clonazepam, commonly known as Klononpin, despite knowing the patient had no legitimate medical need for the drug.” READ MORE

New York suspends nurse for HIPAA violation affecting 3K patients

On June 11, 2018, HealthIT Security reported, “The state of New York has suspended Martha Smith-Lightfoot, a former nurse at the University of Rochester Medical Center (URMC), for a HIPAA violation.

“Smith-Lightfoot admitted to disclosing PHI when she took a list of more than 3,000 patients from URMC to her new employer, Greater Rochester Neurology (GRN), in 2015, explained a June 8 article in the Democrat & Chronicle.” READ MORE

New Colorado law sets 30-day requirement for data breach notification

On June 11, 2018, Credit Union Times reported, “Colorado Gov. John Hickenlooper last week signed bipartisan bill HB18-1128, ‘Protections for Consumer Data Privacy,’ officially setting in place some of the most stringent requirements for personal information data disposal and data breach notification in place in any U.S. state.” READ MORE

Court revives $35 million False Claims Act lawsuit against Brookdale

On June 11, 2018, McKnight’s Senior Care reported, “The 6th Circuit Court of Appeals on Monday reversed a federal court's dismissal of a ‘whistleblower’ lawsuit brought by a former Brookdale Senior Living employee who accused the company and subsidiaries of submitting approximately $35 million in fraudulent Medicare claims for reimbursement.” READ MORE

Grand jury indicts owner of local opioid treatment clinic

On June 11, 2018, Observer-Register (PA) reported, “The latest in a cascade of federal indictments already implicating doctors and a manager has now resulted in charges against the owner of a local clinic treating people for opioid addiction.

“Jennifer Hess, 49, of Washington, is due in U.S. District Court Wednesday for arraignment on charges stemming from a 47-count indictment that included aiding in the distribution of buprenorphine, known as Suboxone and Subutex, conspiracy and health-care fraud.” READ MORE

“No-poach” prosecutions in health care maybe (definitely are) coming

On June 11, 2018, Bloomberg BNA reported, “Barry A. Nigro, Jr., deputy assistant attorney general in the Department of Justice’s antitrust division, said at a recent the American Bar Association antitrust in health care conference in Arlington, VA that no-poach prosecutions are coming.

“No-poach agreements are where firms get together and agree not to ‘poach,’ or solicit or hire, each other’s staff members. The agreements restrict employee movement and are per se illegal, he said. If they are widespread enough, they can have the effect of fixing wages for groups of employees in certain employment markets.” READ MORE

Alabama doctor gets five years in health care fraud case

On June 9, 2018, Associated Press reported, “An Alabama doctor has been sentenced to five years in prison in a health care fraud case.” READ MORE

Court documents reveal suspicions of fraud, theft at nursing home

On June 8, 2018, News 12 (Bronx) reported, “An embattled Bridgeport nursing home and its owner are subjects of a federal grand jury investigation, News 12 has confirmed.” READ MORE

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Regulatory News

CMS Update

PEPPER for Short-term Acute Care Hospitals
First quarter FY 2018 Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) are available for short-term acute care hospitals. These reports summarize provider-specific data statistics for Medicare services that may be at risk for improper payments. Providers can use the data to support internal auditing and monitoring activities. The PEPPER files were recently distributed through a QualityNet secure file exchange to hospital QualityNet Administrators and user accounts with the PEPPER recipient role.

For More Information:

View your MIPS preliminary performance feedback data
If you submitted 2017 Merit-based Incentive Payment System (MIPS) data through the Quality Payment Program website, access preliminary performance feedback data with your Enterprise Identity Management (EIDM) credentials. Your final MIPS score and feedback will be available in July. Between now and June 30, your score could change based on:

  • Special status scoring considerations
  • Final calculations of the All-Cause Readmission Measure for the Quality performance category
  • Inclusion of claims measures from 60-day run out period
  • Results of the CAHPS for MIPS Survey
  • Approval or denial of Promoting Interoperability performance category Hardship Application
  • Improvement Activities Study participation and results
  • Creation of performance period benchmarks for Quality measures that didn’t have a historical benchmark 

If you have questions about your data, contact the Quality Payment Program at 866-288-8292 (TTY: 877-715-6222) or QPP@cms.hhs.gov.

Provider Compliance
Bill correctly for device replacement procedures — Reminder
In a September 2017 report, the Office of the Inspector General (OIG) determined that Medicare paid for many device replacement procedures incorrectly. Hospitals are required to use condition codes 49 or 50 on claims for device replacement procedures resulting from a recall or premature failure (whether the device is provided at no cost or with a credit).

Use the following resources to bill correctly and avoid overpayment recoveries:

In the Federal Register

FR Index 2018 READ MORE

CMS Transmittals

2018: READ MORE

From the OIG

Podcast: Pain Management Doctor Was A One-Man Crime Wave

Updated Civil Monetary Penalties and Affirmative Exclusions

Updated Corporate Integrity Agreement List

Reports
Nebraska Did Not Always Verify Correction of Deficiencies Identified During Surveys of Nursing Homes Participating in Medicare and Medicaid (A-07-17-03224)

Most Medicare Claims for Replacement Positive Airway Pressure Device Supplies Did Not Comply With Medicare Requirements (A-04-17-04056)

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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.