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More than 600 charged in 'largest healthcare fraud takedown in history' - OIG, GAO say CMS isn't doing enough to curb Medicaid fraud - Assistant Inspector General Brian Richie testifies before the US Senate Committee on Homeland Security and Governmental Affairs - And More

Headlines

More than 600 charged in 'largest healthcare fraud takedown in history'

OIG, GAO say CMS isn't doing enough to curb Medicaid fraud

Assistant Inspector General Brian Richie testifies before the US Senate Committee on Homeland Security and Governmental Affairs

Congressional action on Stark Law is critical to developing value-based healthcare

Michigan Medicine notifies 870 patients of PHI compromise

CMS to increase oversight of Medicaid enrollment, managed-care plans

Hospice company to pay $8.5M to settle false claims allegations

Texas physician and two nurses convicted for roles in home health care fraud

LifePoint-owned hospital settles whistleblower lawsuit

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This week’s health care fraud video:

C-Span – June 28, 2018 - Attorney General Sessions News Conference WATCH IT NOW

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Highlights from The Compliance & Ethics Blog

Effective training…Unlocking the magic recipe (it’s both art and science!)

Whether you work for a multinational Fortune 500 organization, mid-size regional firm or a budding startup disrupting a market sector, effective compliance training is a must. Impactful and memorable training is a key factor in influencing your company’s culture and compliance while also shielding your organization from legal risk and protecting its reputation. But, truly effective compliance training is a tricky combination of art and science. Despite the universal yearning for that secret recipe, the magic often results from a careful manipulation of both form and function. If you put 10 top chefs in the same room with the same ingredients and goals – think you’d get the same result? Probably not…therein lies the magic. It’s art and science. READ MORE

Carl Hahn on metrics for your compliance program [Podcast]

Metrics are central for most everything in business, including compliance and ethics.  The key thing, though, is finding the right metrics.  Measure the wrong things, and you won’t know how you program is working.  Measure the right things but in the wrong way, and you can easily be just as lost. READ MORE

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Headlines

More than 600 charged in 'largest healthcare fraud takedown in history'

On June 28, 2018, HealthLeaders Media reported, “More than 600 people—including 76 doctors, 23 pharmacists, 19 nurses, and other medical personnel—have been charged in what U.S. Attorney General Jeff Sessions called ‘the largest healthcare fraud takedown’ in history.”

Per the government press release, “According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided.  In many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of submitting a total of over $2 billion in fraudulent billings.  The number of medical professionals charged is particularly significant, because virtually every health care fraud scheme requires a corrupt medical professional to be involved in order for Medicare or Medicaid to pay the fraudulent claims.  Aggressively pursuing corrupt medical professionals not only has a deterrent effect on other medical professionals, but also ensures that their licenses can no longer be used to bilk the system.” READ MORE | DOJ

OIG, GAO say CMS isn't doing enough to curb Medicaid fraud

On June 28, 2018, FierceHealthcare reported, “Supplemental payments and demonstration programs could be the source of improper payments coming out of the Medicaid program.

“And the Department of Health and Human Services (HHS) needs to do much more to stop the flow, witnesses said in Senate hearing.” READ MORE

Assistant Inspector General Brian Richie testifies before the US Senate Committee on Homeland Security and Governmental Affairs

On June 27, 2018, Assistant Inspector General for Audit Services Brian P. Ritchie presented testimony before the U.S. Senate Committee on Homeland Security and Governmental Affairs entitled “Medicaid Fraud and Overpayments: Problems and Solutions.”

Assistant Inspector General Brian Richie’s testimony concluded with the following:

  • CMS should ensure that national Medicaid data are complete, accurate, and timely.
  • CMS should facilitate State Medicaid agencies’ efforts to screen new and existing providers by ensuring the accessibility and quality of Medicare’s enrollment data.
  • CMS should pursue a means to compel manufacturers to correct inaccurate classification data reported to the Medicaid Drug Rebate Program.
  • CMS should require States to either enroll PCS attendants as providers or require PCS attendants to register with their State Medicaid agencies and assign each attendant a unique identifier.

OIG plans to continue prioritizing Medicaid oversight to prevent and detect fraud, waste, and abuse, and take appropriate action when fraud, waste, or abuse occur. READ MORE

Congressional action on Stark Law is critical to developing value-based healthcare

On June 27, 2018, Becker’s ASC Review reported, “Nearly 30 years ago, Congress enacted legislation known as ‘Stark Law’ that set very specific limits prohibiting physicians like myself from referring patients for tests and services to certain healthcare facilities. Over time, it has become widely recognized that the nation’s healthcare needs are better served by a transition to ‘value-based healthcare,’ which incentivizes providers to improve outcomes while controlling costs. However, achieving this model has been challenging due to Stark Law regulations. Congress recognized that Stark Law creates barriers to value-based healthcare models and thus granted exceptions to hospitals, but unfortunately, did not extend these same waivers to integrated, independent physician practices.” READ MORE

Michigan Medicine notifies 870 patients of PHI compromise

On June 26, 2018, Becker’s Health IT & CIO Report reported, “Ann Arbor-based Michigan Medicine is notifying approximately 870 patients after an employee's personal laptop computer that stored limited health information collected for research was stolen from his car June 3.” READ MORE

CMS to increase oversight of Medicaid enrollment, managed-care plans

On June 26, 2018, Modern Healthcare reported, “The CMS is ratcheting up scrutiny of state Medicaid programs.

“The agency announced Tuesday that it is boosting audits to confirm that Medicaid beneficiaries are correctly identified as expansion or pre-expansion enrollees. States receive higher federal match rates of around 90% for expansion enrollees, while the match rate can be as low as 50% for pre-expansion enrollees.” READ MORE

Hospice company to pay $8.5M to settle false claims allegations

On June 26, 2018, McKnight’s Long-Term Care News reported, “A hospice provider will pay $8.5 million to settle allegations with the government that it provided services to the non-terminally ill in homes and skilled nursing facilities.

“Caris Healthcare — a for-profit hospice provider that operates in Tennessee, Virginia and South Carolina — reached the agreement with the Department of Justice, which said the provider submitted false claims and retained overpayments.

“Caris had ‘aggressive’ admissions and census targets, the DOJ said, and knew about the ineligibility of its payments through internal audits and complaints from executives.” READ MORE

Texas physician and two nurses convicted for roles in home health care fraud

On June 25, 2018, USA Crime Today reported, “A federal jury found one physician and two nurses guilty of home health care fraud, and one physician and one nurse guilty of conspiracy to commit health care fraud, all for their roles in a home health care fraud scheme.

“After a five-day trial, Kelly Robinett, M.D., 70, of Denton County, Texas; and Kingsley Nwanguma, 47, of Dallas County, Texas were each convicted of one count of conspiracy to commit health care fraud.  In addition, Robinett and Nwanguma were each convicted of three counts of health care fraud, and Joy Ogwuegbu, 42, of Collin County, Texas was convicted of four counts of health care fraud. Sentencing before U.S. District Judge Reed O’Connor of the Northern District of Texas, who presided over the trial, has not yet been scheduled.” READ MORE

LifePoint-owned hospital settles whistleblower lawsuit

On June 22, 2018, Nashville Business Journal reported, “A LifePoint Health Inc. facility has settled a whistleblower lawsuit with the U.S. government that alleged Medicare fraud.

“Thursday, the U.S. Justice Department announced a $784,000 settlement with LifePoint’s Livingston Regional Hospital in Livingston, Tenn. The lawsuit was filed pursuant to the False Claims Act by two former employees who worked in the hospital’s geriatric psychiatric unit.” READ MORE

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Regulatory News

CMS Update

2016 CMS Program Statistics
2016 CMS Program Statistics are available, including detailed summary statistics on Medicare populations, utilization, and expenditures, as well as counts for Medicare-certified institutional and non-institutional providers. Tables for calendar years 2013 to 2015 are updated to reflect changes to the source data for enrollment and utilization information. Visit the CMS Program Statistics website for more information.

Physician Self-referral Law RFI: Submit Comments by August 24
On June 20, CMS issued a Request for Information (RFI) seeking public input on reducing the regulatory burdens of the Physician Self-referral Law (also known as the “Stark Law”). Submit comments by August 24.
For More Information see CMS Press Release

Provider Compliance
Comprehensive Error Rate Testing: Arthroscopic rotator cuff repair
As reported in the Medicare Quarterly Compliance Newsletter (October 2017), the Comprehensive Error Rate Testing (CERT) review contractor conducted a study of claims for arthroscopic rotator cuff repairs billed with HCPCS code 29827 submitted from January through March 2016. Most improper payments were due to insufficient documentation.
Avoid documentation errors and payment recoveries:

In the Federal Register

2018 Federal Register items per day: READ MORE

FR Index 2018 READ MORE

CMS Transmittals

2018: READ MORE

From the OIG

2018 National Takedown

-Updated: Work Plan
-Updated Corporate Integrity Agreement List
-Advisory Opinion 18-05 released

Evaluation and Inspection Report
Tennessee Medicaid Fraud Control Unit: 2017 Onsite Inspection
READ MORE

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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.