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Atrium Health to settle federal antitrust suit over health care costs - Owner of Detroit health clinics gets 13 years for $8.9M in Medicare fraud - Doctor and former employee indicted for conspiring to distribute Adderall - And More

Note: Compliance Weekly News will not be sent next week. The next email will be dated Nov. 30, 2018. Happy Thanksgiving!

 

 

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WPTV: FL Doctor recounts her brush with new face of Medicare fraud in Florida

 

 

Headlines

Atrium Health to settle federal antitrust suit over health care costs

Owner of Detroit health clinics gets 13 years for $8.9M in Medicare fraud

Doctor and former employee indicted for conspiring to distribute Adderall

Fraud in the field: Signature compliance

Miami federal judge keeps massive Medicare fraud case on track for trial in January

Health firm’s ex-CEO pleads guilty in Arkansas bribery case

Katy (TX) woman headed to federal prison for orchestrating $5.9 million Medicare scheme at clinic

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CMS Update

From the OIG

In the Federal Register

CMS Transmittals

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Atrium Health to settle federal antitrust suit over health care costs

On November 15, 2018, The Charlotte Observer reported, “North Carolina and federal authorities say they plan to settle their antitrust allegations against Atrium Health, reaching an agreement that they say will lower health care prices for patients.

 

“The 2016 antitrust lawsuit filed against Atrium Health, formerly Carolinas HealthCare System, alleged that the multi-billion-dollar hospital chain illegally reduced competition in the Charlotte health care market.”

 

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DOJ Press Release

 

 

Owner of Detroit health clinics gets 13 years for $8.9M in Medicare fraud

On November 15, 2018, The Detroit News reported, “The owner of two Detroit health clinics was sentenced to 13 years in prison Wednesday for her role in an $8.6 million scheme involving fraudulent Medicare claims.

 

“Jacklyn Price, 34, of Shelby Township, was sentenced by U.S. District Judge Robert Cleland, who also ordered Price to pay $6.3 million in restitution along with her co-conspirators and to forfeit the same amount, the U.S. Attorney’s Office said in a released statement.”

 

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Doctor and former employee indicted for conspiring to distribute Adderall

On November 15, 2018, the U.S. Attorney for Massachusetts announced, “An Uxbridge doctor and her former employee were arrested today and charged in federal court in Boston in connection with a federal drug conspiracy involving the amphetamine Adderall.”

 

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Fraud in the field: Signature compliance

On November 14, 2018, EMS1.com reported, “We all use signatures in our daily life: signing credit cards receipts, writing checks and acknowledging legal documents. As healthcare providers, EMS crewmembers sign their name to PCRs to attest to patient care and might even sign their own name to authorize Medicare claim submission, meeting the requirements of 42 CFR 424.36(b)(6).

 

“PCRs and signature forms, like checks and credit card receipts, are legal documents. But what about forged signatures? We would never forge a check, or sign someone else’s name on a legal instrument, right? So, why should EMS providers ever consider signing a patient’s name for claim submission purposes? Although it sounds bad, it’s happened – quite a bit. The fact that it’s occurring is alarming. The fact that it can often go undetected is even more alarming.”

 

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Miami federal judge keeps massive Medicare fraud case on track for trial in January

On November 14, 2018, Miami Herald reported, “In the nation’s biggest Medicare fraud case, a federal judge decided Tuesday to keep the trial of a wealthy Miami Beach businessman on track — despite finding problems with the conduct of prosecutors and agents.

 

In his ruling, U.S. District Judge Robert Scola found that while they ‘failed to uphold the high standards’ expected of them, federal law enforcement agencies did not act in ‘bad faith’ during their investigation and prosecution of Philip Esformes. Detained since his arrest more than two years ago, Esformes, 49, is charged in a $1 billion Medicare fraud scheme and faces trial in January.”

 

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Health firm’s ex-CEO pleads guilty in Arkansas bribery case

On November 13, 2018, Associated Press reported, “A top executive at a Missouri mental health company has pleaded guilty to helping bribe Arkansas lawmakers to influence state legislation and boost company profits.

 

“Marilyn Nolan, former CEO of Preferred Family Healthcare Inc., pleaded guilty last week to conspiracy in federal court in Springfield, Missouri, according to court records.”

 

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Katy (TX) woman headed to federal prison for orchestrating $5.9 million Medicare scheme at clinic

On November 7, 2018, Houston Chronicle reported, “A clinic owner who orchestrated a $5.9 million Medicare fraud with fake tests and an unlicensed doctor was sentenced Wednesday in Houston to serve three years in federal prison.

“U.S. District Judge Kenneth M. Hoyt handed down the sentence to Joy Aneke, 51, of Katy who was convicted of recruiting Medicare patients and billing them at her clinics for expensive tests that were neither medically necessary or performed.”

 

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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

 

DME: Denial of Serial Claims

CMS identified Durable Medical Equipment (DME) items that are serial in nature. For these items, we generally review the first claim in the series and:

  • Pay subsequent claims in the series after passing existing validation edits, or
  • Deny subsequent claims in the series unless you submit additional documentation with the subsequent claim line

If a serial claim is denied after a complex medical review, subsequent claims in the series will be denied unless additional documentation is submitted to demonstrate that the services are reasonable and medically necessary.

  • If a paper claim is submitted, attach any additional documentation to the claim form
  • If an electronic claim is submitted, follow the existing PWK process and include the word “serial” in the NTE02 segment of the claim; refer to MLN Matters® Article MM7041

Check your Medicare Administrative Contractor’s website for additional information, including a list of impacted HCPCS codes.

 

 

Provider Compliance: Cochlear Devices Replaced Without Cost: Bill Correctly — Reminder

In November 2016, the Office of the Inspector General (OIG) reported that hospitals did not always comply with Medicare requirements for reporting cochlear devices replaced without cost to the hospital or beneficiary. In 116 of 149 claims reviewed, hospitals did not report the appropriate modifiers and charges or a combination of the appropriate value code and condition codes. Medicare Administrative Contractors use this information to adjust payment; incorrect billing led to Medicare overpayments of $2.7 million.

  • Services furnished on or after January 1, 2014: outpatient hospitals should report value code “FD” along with condition code 49 or 50
  • Services furnished prior to January 1, 2014: outpatient hospitals should report the modifier “FB” on the same line as the procedure code (not the Cochlear Device code)

Use the following resources to bill correctly and avoid overpayment recoveries:

 

 

 

 

In the Federal Register

Current Items

2018 FR Index

 

 

CMS Transmittals

View 2018 Transmittals

 

 

Acronym Library

Find CMS Acronyms

 

Product Features

 

Workplace Investigations: Techniques and Strategies for Investigators and Compliance Officers

 

Learn More

 

 

Building An Ethical Culture: Why It's Vital, How It's Done

 

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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.