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Detroit Medical Center facing surprise inspection from state, federal regulators - St. Louis chiropractor sentenced, fined for health care fraud and bribery scheme - Owners of Quincy health care firm charged in $1M tax fraud - And more

Headlines

Detroit Medical Center facing surprise inspection from state, federal regulators

 

St. Louis chiropractor sentenced, fined for health care fraud and bribery scheme

Owners of Quincy health care firm charged in $1M tax fraud

CVS Health and Aetna $69B merger is approved with conditions

Former psychiatrist in Southwest Va. pleads guilty to fraud

Miami-area pharmacy owner pleads guilty

Former billing clerk at Preferred Family Health accused of Medicaid fraud

Texas hospital administrator convicted of health care fraud

Recruiter sentenced to prison for role in $3.6M fraud

Regulatory News

CMS Update

From the OIG

In the Federal Register

CMS Transmittals

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Health Care Privacy Compliance Handbook, Second Edition

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Detroit Medical Center facing surprise inspection from state, federal regulators

On October 11, 2018, Modern Healthcare reported, “Detroit Medical Center soon faces a surprise quality inspection from state and federal regulators, according to an official from the Chicago office of the Centers for Medicare and Medicaid Services. CMS said Wednesday it has authorized an investigation at Harper University Hospital and Detroit Receiving Hospital in response to recent media reports to determine whether the facilities are in compliance with the agency's Conditions of Participation.”

 

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St. Louis chiropractor sentenced, fined for health care fraud and bribery scheme

On October 11, 2018, KSDK-TV 5 reported, “A St. Louis chiropractor has been sentenced to 30 months in prison and fined $350,000 for his role in a scheme to illegally obtain confidential information from the St. Louis Police Department.

“Mitchell Davis, DC, 50, admitted to a scheme where he and his wife solicited unreduced police reports in exchange for cash payments from St. Louis Police officers who had access to the reports. The reports included names and personal information of individuals involved in car accident in St. Louis.”

 

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Owners of Quincy health care firm charged in $1M tax fraud

On October 10, 2018, The Patriot Ledger (MA) reported, “The co-owners of a Quincy home health care company have been charged in federal court with underreporting $1.1 million in income to the Internal Revenue Service.

 

“Hannah Holland, 51, of Quincy, and Sheila O’Connell, 33, of North Weymouth, operated Erin’s Own Home Healthcare Inc. at 76 South Walnut St.”

 

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CVS Health and Aetna $69B merger is approved with conditions

On October 10, 2018, The New York Times reported, “The Justice Department’s approval of the $69 billion merger between CVS Health and Aetna on Wednesday caps a wave of consolidation among giant health care players that could leave American consumers with less control over their medical care and prescription drugs.

 

“The approval marks the close of an era, during which powerful pharmacy benefit managers brokered drug prices among pharmaceutical companies, insurers and employers.”

 

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Former psychiatrist in Southwest Va. pleads guilty to fraud

On October 10, 2018, Virginia Business reported, “A former psychiatrist who used to work in Lebanon is facing serious jail time and fines after carrying on a sexual relationship with a patient.

 

“Alfredo Cervantes, 62, pled guilty to one count of health-care fraud and one count of wire fraud, according to an announcement Wednesday from U.S. Attorney Thomas T. Cullen and Virginia Attorney General Mark Herring.”

 

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Miami-area pharmacy owner pleads guilty

On October 9, 2018, Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division announced in a press release, “The owner of a Miami-area pharmacy pleaded guilty for his role in Medicare prescription fraud scheme involving approximately $8.4 million in fraudulent billings.”

 

According to the government press release, “Antonio Perez Jr., 48, of Miami Beach, Florida, pleaded guilty today before U.S. District Judge Federico A. Moreno to one count of conspiracy to commit health care fraud.”

 

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Former billing clerk at Preferred Family Health accused of Medicaid fraud

On October 9, 2018, KATV (AR) reported, “A former billing clerk at Preferred Family Health faces charges related to Medicaid fraud, according to Arkansas' attorney general.

 

“Batesville's Vicki Chisam, 65, is accused of knowingly making false statements that caused the Arkansas Medicaid Program to overpay Preferred Family Health approximately $589,000 from January to November 2015, authorities say.”

 

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Texas hospital administrator convicted of health care fraud

On October 9, 2018, Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division announced in a press release, “A federal jury convicted a Houston-area hospital administrator on Friday for his role in a $16 million Medicare fraud scheme.”

 

According to the government press release, “Starsky D. Bomer, 45, of Harris County, Texas, was convicted of one count of conspiracy to pay and receive healthcare kickbacks, two counts of violating the Anti-Kickback Statute, and one count of conspiracy to commit health care fraud following a five-day trial. Sentencing has been scheduled for Jan. 28, 2019 before U.S. District Judge Vanessa D. Gilmore of the Southern District of Texas, who presided over the trial.”

 

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Recruiter sentenced to prison for role in $3.6M fraud

On October 8, 2018, Houston Patch reported, “A 52-year-old woman has been sentenced to nine years in prison for her role in a $3.6 million Medicare fraud scheme. Mercy Ainabe, who worked for Texas Tender Care, was found guilty of selling Medicare patients' personal info to home health care companies in exchange for kickbacks, the FBI tweeted. Ainabe was found guilty May 2, the Department of Justice wrote in a news release.”

 

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Managed Care Compliance Conference | January 27-30, 2019 | Lake Buena Vista, FL | Learn More >Managed Care Compliance Conference | January 27-30, 2019 | Lake Buena Vista, FL | Learn More >

 

CMS Update

 

Provider Compliance - Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

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

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CMS Transmittals

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Product Features

 

Health Care Privacy Compliance Handbook, Second Edition

 

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Building a Career in Compliance and Ethics

 

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Register for the 4th Annual Healthcare Enforcement Compliance Conference | Nov 4-7 in DC | Learn more >Register for the 4th Annual Healthcare Enforcement Compliance Conference | Nov 4-7 in DC | Learn more >

 

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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.