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Pain clinics change hands amid federal fraud probe - Guilty verdict reinstated for KY doctor accused of doing unneeded heart procedures - Children’s Mercy faces class action lawsuit over data breach affecting thousands - And More

Headlines

Pain clinics change hands amid federal fraud probe

Guilty verdict reinstated for KY doctor accused of doing unneeded heart procedures

Children’s Mercy faces class action lawsuit over data breach affecting thousands

Santa Fe cardiologist gets prison term for health care fraud

Health Quest paying more than $15M to settle suit over false claims

Liberty Ambulance agrees to $1.2 million settlement

'Bagman' gets five years in prison for role in American Senior Communities scheme

Former Vero Beach doctor Johnny Benjamin sentenced to life in prison

Preferred Care settles for $540,000 in whistleblower upcoding case

Johns Hopkins Hospital buildings evacuated for possible tuberculosis contamination

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This week’s health care fraud video:

CBS New York: Possible tuberculosis exposure at Johns Hopkins WATCH IT NOW

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News of Interest

Daily Beast: “HHS Plans to Delete 20 Years of Critical Medical Guidelines Next Week” READ MORE

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Highlights from The Compliance & Ethics Blog

Kristy Grant-Hart on building a successful compliance career [Podcast]

A compliance job is rarely easy.  And, sometimes, as was discussed in a recent podcast, you may find yourself having to leave a job.  But the chances of having a good, successful career in compliance are much better, if you spend some time planning it out. READ MORE

N is for negligence

I am not even sure where to begin this brief journey through corporate missteps, the motivations behind them, and their consequences.  It’s a little like my previous conversation with you in “M is for metrics”.  We’re good at measuring the failures.  Not so good at rewarding the many daily successes.  Here, the examples come with death and destruction. READ MORE

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Headlines

Pain clinics change hands amid federal fraud probe

On July 11, 2018, Carolina Public Press reported, “Pain clinics in Winston-Salem and Roanoke Rapids have come under new ownership as their Tennessee-based parent company has closed practices in multiple states and its former CEO faces Medicare fraud charges. Other clinics in North Carolina are also facing changes.” READ MORE

Guilty verdict reinstated for KY doctor accused of doing unneeded heart procedures

On July 10, 2018, Lexington Herald-Leader reported, “A panel of federal judges has reinstated the criminal conviction of an Ashland physician accused of performing unnecessary heart procedures in order to run up profits.

“The appeals court decision left open the possibility that Richard E. Paulus, who retired after coming under investigation, could receive a new trial.” READ MORE

Children’s Mercy faces class action lawsuit over data breach affecting thousands

On July 10, 2018, The Kansas City Star reported, “A Kansas City law firm filed a class action lawsuit this week against Children’s Mercy Hospital after personal data from more than 60,000 individuals may have been compromised as part of an email phishing scam that targeted hospital employees.” READ MORE

Santa Fe cardiologist gets prison term for health care fraud

On July 10, 2018, KCBD reported, “A Santa Fe cardiologist has been sentenced to more than four years in federal prison for health care fraud and obstruction of justice.”

According to the report Roy G. Heilbron, a cardiologist, will “pay nearly $624,000 in restitution to the victims of the health care fraud.” READ MORE

Health Quest paying more than $15M to settle suit over false claims

On July 10, 2018, Daily Freeman (NY) reported, “Federal authorities say Health Quest and a subsidiary hospital have agreed to pay more than $15 million to the U.S. government and New York state to settle a false claims lawsuit.

“Dutchess County-based Health Quest Systems and Putnam Health Center in Putnam County will pay $14.7 million to resolve allegations of violating the federal False Claims Act, according to the U.S. Attorney’s Office in Syracuse.” READ MORE

Liberty Ambulance agrees to $1.2 million settlement

On July 10, 2018, Jacksonville Daily Reporter reported, “Jacksonville-based Liberty Ambulance Service Inc. has agreed to a $1.2 million settlement of allegations that it, for more than 10 years, fraudulently billed federal health benefits providers for transportation of patients.

“According to a news release Tuesday from the U.S. Attorney's Office Middle District of Florida, the settlement is the result of a multiyear investigation that alleged that between June 29, 2005, and January 2016, Liberty Ambulance knowingly up-coded claims for life support services from ‘basic’ to ‘advanced’ without justification and also unnecessarily transported patients.” READ MORE

'Bagman' gets five years in prison for role in American Senior Communities scheme

On July 9, 2018, Indianapolis Star reported, “Steven Ganote, described by prosecutors as the ‘bagman’ behind a lucrative nursing home fraud scheme, was sentenced Monday to five years in prison.

“And Josh Burkhart, brother of the former American Senior Communities CEO who orchestrated the scheme, was sentenced to four months in prison for his role.” READ MORE

Former Vero Beach doctor Johnny Benjamin sentenced to life in prison

On July 6, 2018, TC Palm reported, “Former Vero Beach doctor Johnny Benjamin was sentenced Friday to spend the rest of his life in prison after being convicted in a federal drug case tied to a Palm Beach County woman's 2016 overdose death.” READ MORE

Preferred Care settles for $540,000 in whistleblower upcoding case

On July 6, 2018, McKnight’s Long-Term Care News reported, “Nursing home chain Preferred Care agreed to settle False Claims Act charges for $540,000, the Department of Justice has announced.

“Federal officials accused the company of upcoding Medicare beneficiaries between July 2012 and October 2017, and of providing ‘worthless services’ at Kentucky's Stanton Nursing and Rehabilitation Center for three years.” READ MORE

Johns Hopkins Hospital buildings evacuated for possible tuberculosis contamination

On July 5, 2018, The Baltimore Sun reported, “Two cancer research buildings at Johns Hopkins Hospital were evacuated Thursday due to possible tuberculosis contamination, according to the hospital.

“The Baltimore City Fire Department investigated the release of a small amount of frozen tuberculosis in a bridge between the two buildings in the 1500 block of Orleans Street, said Kim Hoppe, a spokeswoman for the hospital, in a statement.” READ MORE

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Regulatory News

CMS Update

MIPS 2019 Payment Adjustment Fact Sheet
CMS posted a Fact Sheet to help eligible clinicians and groups understand their Merit-based Incentive Payment System (MIPS) 2019 payment adjustment based on their 2017 performance. The fact sheet highlights how CMS assigns final scores to MIPS eligible clinicians and how payment adjustment factors are applied for 2019 based on 2017 MIPS final scores.
For More Information:

Provider Compliance
Proper use of the KX Modifier for Part B Immunosuppressive drug claims — Reminder
A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B for claims using the KX modifier for immunosuppressive drugs. It is estimated that Medicare paid $4.6 million for these claims that did not comply with Medicare requirements.
In response to this report, CMS clarified manual instructions on the use of the KX modifier to help pharmacies document the medical necessity of organ transplant and eligibility for Medicare coverage. Resources for pharmacies:

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

OIG Reports

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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.