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Nurse practitioner and technician plead guilty - Thousands of people’s insurance appeals went to a doctor feds say is a fraud - Glenview (IL) psychologist charged with health care fraud - And More

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Nurse practitioner and technician plead guilty

Thousands of people’s insurance appeals went to a doctor feds say is a fraud

Glenview (IL) psychologist charged with health care fraud

Justice Dept. awards nearly $320M to tackle opioid crisis across US

AmerisourceBergen to pay $625 million in U.S. civil fraud settlement

Feds settle huge whistleblower suit over Medicare Advantage fraud

Kalispell Regional settles whistleblower suit for $24M

TRICARE wins settlement against now-defunct pharmacy

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CMS Update

From the OIG

In the Federal Register

CMS Transmittals

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The First Information Is Almost Always Wrong

Health Care Privacy Compliance Handbook, Second Edition

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Nurse practitioner and technician plead guilty

On October 3, 2018, U.S. Attorney for the District of Nevada Dayle Elieson announced, “A nurse practitioner and a surgical technician pleaded guilty in federal court Tuesday in connection to the unlawful distribution of prescription opioids and for committing Medicare and Medicaid fraud.

 

“Robert D. Harvey, a surgical technician, 45, of Henderson, pleaded guilty to one count of conspiracy to distribute a controlled substance and three counts of distribution of a controlled substance, and Alejandro ‘Alex’ Incera, aka Alexander Jiminez-Incera, an Advance Practice Registered Nurse, 48, of Las Vegas, pleaded guilty to eight counts of distribution of controlled substance and eight counts of health care fraud.”

 

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Thousands of people’s insurance appeals went to a doctor feds say is a fraud

On October 2, 2018, Bloomberg News reported, “For years, Spyros Panos seemed like a successful orthopedic surgeon, seeing dozens of patients a day and bringing in millions of dollars in fees for his suburban New York medical group.

“In fact, he was inflating charges and billing for surgeries he didn’t perform, perpetrating a years-long fraud that culminated in a guilty plea on a single count in federal court in 2013.

“That was the end of his surgical practice. But even as he was waiting to be sentenced, federal prosecutors say, Panos was beginning a new criminal scheme that would go undetected for years until he was arrested again in April.”

 

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Glenview (IL) psychologist charged with health care fraud

On October 2, 2018, Chicago Sun Times reported, “A psychologist who practiced in north suburban Glenview was indicted on federal fraud charges after allegedly submitting false claims to Medicare and private insurers.

 

“Pamela Antell, 66, of Deerfield, was charged with five counts of health care fraud and three counts of aggravated identity theft, according the U.S. Attorney’s Office for the Northern District of Illinois.”

 

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Justice Dept. awards nearly $320M to tackle opioid crisis across US

On October 1, 2018, WTOP reported, “The Department of Justice is awarding nearly $320 million to help fund the fight against the opioid crisis across the U.S., with grant recipients in Maryland and Virginia receiving support in their programs.”

 

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AmerisourceBergen to pay $625 million in U.S. civil fraud settlement

On October 1, 2018, Reuters reported, “AmerisourceBergen Corp, one of the largest U.S. drug wholesalers, will pay $625 million to resolve civil fraud charges over the sale of syringes containing drugs for cancer patients, double billing, and providing kickbacks to doctors.”

 

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Feds settle huge whistleblower suit over Medicare Advantage fraud

On October 1, 2018, Kaiser Health News reported, “One of the nation’s largest dialysis providers will pay $270 million to settle a whistleblower’s allegation that it helped Medicare Advantage insurance plans cheat the government for several years.

"The settlement by HealthCare Partners Holdings LLC, part of giant dialysis company DaVita Inc., is believed to be the largest to date involving allegations that some Medicare Advantage plans exaggerate how sick their patients are to inflate government payments.”

 

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Kalispell Regional settles whistleblower suit for $24M

On September 28, 2018, Flathead Beacon (MT) reported, “Kalispell Regional Healthcare has agreed to pay $24 million to settle a whistleblower lawsuit with the Department of Justice, which during the course of its investigation alleged that 63 physicians were involved in an illegal kickback scheme to boost revenues and enrich themselves, a violation of the federal Anti-Kickback Statute, the False Claims Act and the Stark Law, which prohibit physician self-referrals.”

 

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TRICARE wins settlement against now-defunct pharmacy

On September 28, 2018, Tampa Bay Business Journal reported, “According to the U.S. attorney's office, the now-defunct RS Compounding LLC, and its owner, Renier Gobea, charged TRICARE more than they charged the public, which, in some cases was more than 10,000 percent, between January 1, 2012, and January 31, 2014, resulting in violation of the False Claims Act.”

 

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CMS Update

 

ABNs and Dual Eligible Beneficiaries: Special Guidelines

When Advance Beneficiary Notices (ABNs) are issued to dual eligible beneficiaries, including Qualified Medicare Beneficiaries (QMBs), distinct billing limitations apply. See QMB Billing Requirements FAQs pages 6 and 7 for special instructions and guidelines.

For More Information:

 

 

Provider Compliance – Outpatient Services Payment: Beneficiaries Who Are Inpatients of Other Facilities — Reminder

In a recent report, the Office of the Inspector General (OIG) determined that Medicare inappropriately paid acute-care hospitals for outpatient services provided to beneficiaries who were inpatients of other facilities, including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. As a result, beneficiaries were unnecessarily charged outpatient deductibles and coinsurance payments.

 

All items and non-physician services provided during a Medicare Part A inpatient stay must be provided directly by the inpatient hospital or under arrangements with the inpatient hospital and another provider.

 

Use the following resources to bill correctly:

 

 

 

 

In the Federal Register

Current Items

2018 FR Index

 

 

CMS Transmittals

View 2018 Transmittals

 

 

Acronym Library

Find CMS Acronyms

 

Product Features

 

The First Information Is Almost Always Wrong

 

Learn More

 

 

Health Care Privacy Compliance Handbook, Second Edition

 

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Questions/Feedback?

Please feel free to contact Margaret Dragon, editor of Compliance Weekly News.

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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.