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Owner of durable medical equipment company pleads guilty to defrauding Medicaid of more than $9M - Carl Junction (MO) pharmacist pleads guilty to health care fraud - Puerto Rican doctor arrested for health care fraud - And More

Headlines

Owner of durable medical equipment company pleads guilty to defrauding Medicaid of more than $9M

Carl Junction (MO) pharmacist pleads guilty to health care fraud

Puerto Rican doctor arrested for health care fraud

Speech pathologist guilty of healthcare fraud sentenced to probation

Judge upholds Arkansas' suspension of Medicaid payments to provider

New Joint Commission advisory on pressure injuries related to medical devices

Be prepared: Provider-based mid-build audits are here

Texas Medical Board revokes license for Bryan doctor

Bon Secours Health System, Mercy Health to complete merger in the fall

South Carolina doctor risked it all to blow the whistle on a national Medicare fraud

Plea deal proposal outlines alleged multimillion health care fraud scheme in Merced

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This week’s health care fraud video:

ABC 5 TV: “Thousands of medical records left unsecured--So who’s investigating?” WATCH IT NOW

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Headlines

Owner of durable medical equipment company pleads guilty to defrauding Medicaid of more than $9M

On July 25, 2018, Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division announced, “Waveney Blackman, 72, of Bowie, Maryland, pleaded guilty in the U.S. District Court for the District of Columbia.  Her sentencing is scheduled on Oct. 18 before the Honorable Thomas F. Hogan. 

“Blackman was the sole owner and chief executive officer of WaveCare Health Services LLC, also known as WaveCare Healthcare Services LLC.  The company, based in the District of Columbia, was a provider of durable medical equipment, including wound care and incontinence supplies, to Medicaid beneficiaries and others.  It became a Medicaid provider in 2008.” READ MORE

Carl Junction (MO) pharmacist pleads guilty to health care fraud

On July 24, 2018, The Joplin Globe reported, “A Carl Junction pharmacist pleaded guilty Monday to a felony charge of health care fraud in federal court for submitting false Medicare, Medicaid and Tricare claims.” READ MORE

Puerto Rican doctor arrested for health care fraud

On July 24, 2018, Caribbean Business reported, “On July 19, a federal grand jury in the District of Puerto Rico returned an indictment charging Dr. Miguel Rivera-Sanabria, who was arrested Tuesday, with 18 counts of health care fraud, three counts of aggravated identity theft, three counts of false statement and eight counts for attempted distribution of controlled substances, the Justice Department announced.

“According to a release, from about August 2013 to August 2017, Rivera-Sanabria ‘enriched himself by submitting false and fraudulent claims to Medicare through claims submissions to Medicare Advantage plans for medical services that were never performed,’ billing Medicare $252,055 and receiving ‘$225,250 based on these false and fraudulent claims.’” READ MORE

Speech pathologist guilty of healthcare fraud sentenced to probation

On July 24, 2018, The Brownsville Herald reported, “An Olmito speech pathologist was sentenced to five years probation and ordered to pay nearly a half million dollars in restitution after being found guilty earlier this year of conspiring to defraud Texas Medicaid through fraudulent billings.” READ MORE

Judge upholds Arkansas' suspension of Medicaid payments to provider

On July 24, 2018, Arkansas Online reported, “Arkansas officials acted properly in suspending Medicaid payments to a Missouri-based behavioral health provider, an administrative law judge ruled Monday.

“Arkansas Medicaid Inspector General Elizabeth Smith suspended the payments to Preferred Family Healthcare on June 29 after a former executive with the nonprofit was arrested in the improper billing of almost $2.3 million in claims for mental health services.” READ MORE

New Joint Commission advisory on pressure injuries related to medical devices

On July 24, 2018, The Joint Commission issued a press release noting, “Pressure injuries related to medical devices—including feeding or oxygen delivery tubes, catheters, orthopedic devices, bedpans and casts—now account for more than 30 percent of all hospital-acquired pressure injuries, and are a known significant cause of patient morbidity.

“Preventing them is the focus of a new advisory from The Joint Commission. Quick Safety, Issue 43: ‘Managing medical device-related pressure injuries’ provides strategies for health care professionals to prevent these injuries.” READ MORE

Be prepared: Provider-based mid-build audits are here

On July 23, 2018, The National Law Review reported, “Hospitals with off-campus provider-based departments (PBDs) under construction (or mid-build) at the time of the Bipartisan Budget Act of 2015 – which limited Medicare payment to off-campus provider-based departments that were not operational prior to November 2, 2015– have been waiting years for Medicare to confirm the provider-based status of these locations. With mid-build audits underway, it appears hospitals are one step closer to that goal.” READ MORE

Texas Medical Board revokes license for Bryan doctor

On July 23, 2018, KBTX-TV reported, “The Texas Medical Board has revoked the medical license for a local doctor who was convicted of health care fraud in 2017.

“During the board's June meeting, a final order was issued against Dr. Ronald F. Kahn. A federal jury convicted Kahn last year for his role in a scheme involving approximately $1.5 million in fraudulent Medicare claims for home health care services and various medical testing and services.” READ MORE

Bon Secours Health System, Mercy Health to complete merger in the fall

On July 23, 2018, The Baltimore Sun reported, “Marriottsville-based Bon Secours Health System and Mercy Health of Ohio expect to complete their merger in the fall, officials with both said Monday. Mercy Health President and CEO John M. Starcher Jr. will head the new health system, while Bon Secours board chairman Chris Allen will lead the new board.”

According to the report, “Cory Capps, an economist with Bates White Economic Consulting who studies health care antitrust issues, says the merger is unlikely to raise antitrust concerns because the hospitals are in different states.” READ MORE

South Carolina doctor risked it all to blow the whistle on a national Medicare fraud

On July 23, 2018, Greenville News reported, “Dr. Michael Mayes sits in his Hilton Head Island home, ready to tell his story.

“But he’s stiff.

“His attorney is on speaker phone.

“They say they can’t name names.

“Mayes, an internal medicine physician, has reason to be uneasy.

“Since 2010, he’s worked mostly in secret to gather information, turn it over to the government and help build a federal case to expose national Medicare fraud that affected his own patients on Hilton Head — and those around South Carolina and the nation too.” READ MORE

Plea deal proposal outlines alleged multimillion health care fraud scheme in Merced

On July 20, 2018, Merced Sun-Star reported, “The embattled ex-CEO of a string of now-shuttered Merced-area health clinics that served thousands of low-income patients has signed an agreement to plead guilty to defrauding Medi-Cal of millions of dollars.

“According to a copy of the document filed July 13 in U.S. District Court, Sandra Haar, former head of Horisons Unlimited Health Care, falsified medical and billing records and pocketed ‘kickback’ payments to route work to a medical-testing laboratory dating back to at least 2014, according to documents filed in U.S. District Court.” READ MORE

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Regulatory News

Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule advances CMS commitment to increasing transparency and lowering drug prices

On July 25, the Centers for Medicare and Medicaid Services announced in a press release, “CMS took steps to strengthen the Medicare program with proposed changes to ensure that seniors can access the care they need at the site of care that they choose. In addition, as part of the agency’s ongoing efforts to lower drug prices as outlined in the President’s Blueprint, CMS included a Request for Information on how best to develop a model leveraging authority provided to the agency under the Competitive Acquisition Program (CAP) to strengthen negotiations for prescription drugs.” READ MORE

CMS Update

NF QRP Non-Compliance Letters: Request for Reconsideration by August 7
CMS provided notifications to facilities that were determined to be out of compliance with Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) requirements for CY 2017. This will affect your FY 2019 Annual Payment Update. Non-compliance notifications were mailed by Medicare Administrative Contractors and placed into QIES CASPER folders on July 9.

If you receive a letter of non-compliance, you may submit a request for reconsideration to CMS via email no later than 11:59 pm PT on August 7. See the instructions in your notification letter and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

Provider Compliance

Proper coding for specimen validity testing billed in combination with urine drug testing

In a February 2018 report, the Office of the Inspector General (OIG) determined that Medicare payments to clinical laboratories and providers for specimen validity tests did not comply with Medicare billing requirements. A recent MLN Matters® Special Edition Article reminds laboratories and other providers about proper billing for specimen validity testing done in conjunction with drug testing; this article contains no policy changes.

Current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient. This article includes descriptors for:

  • Presumptive drug testing codes
  • Definitive drug testing codes

Use the following resources to bill correctly and avoid overpayment 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

Updated Stipulated Penalties and Exclusion for Material Breach

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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.