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Two physicians, three nurses sentenced to prison for role in $11M billing scheme - Insurer Anthem will pay record $16M for massive data breach - NY Attorney General announced convictions of three Nassau County nursing home staff for neglect - And More

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Two physicians, three nurses sentenced to prison for role in $11M billing scheme

Insurer Anthem will pay record $16M for massive data breach

NY Attorney General announced convictions of three Nassau County nursing home staff for neglect

Overland Park doctor was a model for opioid firm under indictment, Senate report says

Primera Medical Group execs charged with healthcare fraud

Physician charged with 26 counts of healthcare fraud

Seven companies, four men charged in $1B telemedicine fraud scheme

Father, son plead guilty to $27M health care scam

Mich. health-care CEO pleads guilty in $300M fraud scheme

Sloan Kettering researchers correct the record by revealing company ties

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Two physicians, three nurses sentenced to prison for role in $11M billing scheme

On October 17, 2018, Becker Hospital Review reported, “Two physicians in Dallas and three nurses were sentenced to prison Oct. 16 for their roles in an $11.3 million Medicare fraud scheme, according to the Department of Justice.”

 

According to the report, “Kelly Robinett, MD, former part-owner and supervising physician at Frisco, Texas-based Boomer House Calls, was sentenced to three and a half years in prison for certifying Medicare beneficiaries, even though he did not see them, for medically unnecessary services.”

 

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DOJ Press Release

 

 

Insurer Anthem will pay record $16M for massive data breach

On October 15, 2018, RTV6 (IN) reported, “The nation's second-largest health insurer has agreed to pay the government a record $16 million to settle potential privacy violations in the biggest known health care hack in U.S. history, officials said Monday.

 

“The personal information of nearly 79 million people — including names, birthdates, Social Security numbers and medical IDs — was exposed in the cyberattack, discovered by the company in 2015.”

 

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NY Attorney General announced convictions of three Nassau County nursing home staff for neglect

On October 16, 2018, New York Attorney General Barbara D. Underwood announced, “the convictions of two registered nurses, Sijimole Reji and Annieamma Augustine, and a certified nurse aide, Martine Morland, for neglecting an 81-year-old ventilator-dependent resident of A. Holly Patterson Extended Care Facility in Uniondale.”

 

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Overland Park doctor was a model for opioid firm under indictment, Senate report says

On October 16, 2018, Kansas City Star reported, “Internal emails from an opioid manufacturer under federal indictment for an alleged kickback scheme show that company executives held Overland Park doctor Steven Simon as one of their models for their sales force.

 

“The emails are included in a report released Tuesday by U.S. Senate committee staffers and provide new details about Simon’s relationship with Insys Therapeutics. The Arizona company’s former leaders face charges they used a physician speaker program to pay doctors for prescribing their fentanyl product Subsys, a highly concentrated opioid sprayed under the tongue.”

 

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Primera Medical Group execs charged with healthcare fraud

On October 15, 2018, Atlanta Patch reported, “The CEO and COO of Atlanta-based Primera Medical Group have been arraigned on federal charges that they submitted more than 4,500 fraudulent claims for allergy treatments. CEO Shailesh Kothari and COO Timothy McMenamin have been charged for their alleged roles in the scheme, in which prosecutors say they sought more than more than $8.5 million in insurance payments after submitting the claims.”

 

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Physician charged with 26 counts of healthcare fraud

On October 15, 2018, Becker’s Hospital Review reported, “A Florida physician faces 26 charges of healthcare fraud related to claims submitted to the government and commercial insurers dating as far back as 2014, according to the Department of Justice.

 

“The department alleges Sheetal Kanar Kumar, MD, an obstetrician and gynecologist, filed false claims to Medicare, Medicaid and private insurance companies out of her practice in Stuart, Fla.”

 

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Seven companies, four men charged in $1B telemedicine fraud scheme

On October 15, 2018, Associated Press reported, “Seven companies and four men are facing charges, accused of roles in a $1 billion telemedicine fraud scheme that deceived tens of thousands of patients and more than 100 doctors, federal prosecutors announced Monday.”

 

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Father, son plead guilty to $27M health care scam

On October 15, Associated Press reported, “A father and son from California have pleaded guilty for their roles in a scheme that defrauded more than $27 million from Affordable Care Act programs in at least 12 states.”

 

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Mich. health-care CEO pleads guilty in $300M fraud scheme

On October 15, 2018, The Detroit News reported, “A Metro Detroit health care CEO pleaded guilty Monday in an investigation into a $300 million scheme to distribute 6.6 million doses of controlled substances, federal authorities said.”

 

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Sloan Kettering researchers correct the record by revealing company ties

On October 12, 2018, The New York Times reported, “Top researchers at Memorial Sloan Kettering Cancer Center have filed at least seven corrections with medical journals recently, divulging financial relationships with health care companies that they did not previously disclose.”

 

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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

 

Hand in Hand: A Training Series for Nursing Homes

Do you need in-service training on dementia management and resident abuse prevention? Hand in Hand: A Training Series for Nursing Homes focuses on caring for residents with dementia and preventing abuse. This training is updated and available in two formats:

For help with registration and technical issues, contact the Helpdesk at cmstraininghelp@hendall.com.

 

 

 

Provider Compliance―Cardiac Device Credits: Medicare Billing

A 2018 Office of the Inspector General (OIG) Report noted that payments reviewed for recalled cardiac medical devices did not comply with Medicare requirements for reporting manufacturer credits. Medicare incorrectly paid hospitals $7.7 million for cardiac device replacement claims, resulting in potential overpayments of $4.4 million. Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals did not adjust the claims with the proper condition codes, value codes, or modifiers to reduce payment as required.

 

CMS developed the Medicare Billing for Cardiac Device Credits Fact Sheet to ensure that hospitals properly report manufacturer credits for cardiac devices and avoid overpayment recoveries. Additional resources:

 

 

 

 

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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.