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Digital transformation demands a whole new level oversight to avoid healthcare fraud - HIPAA penalties for failure to cut off access to former employee - Coordinated Health, CEO pay $12.5M to resolve fraud allegations - And More

Headlines

Digital transformation demands a whole new level oversight to avoid healthcare fraud

HIPAA penalties for failure to cut off access to former employee

Coordinated Health, CEO pay $12.5M to resolve fraud allegations

Kingwood resident indicted in connection with more than $4M in health care fraud

Thomson businesswoman convicted of fraud

Rich and on the run: Doctors flee country amid fraud, opioid crackdown

Aurora to pay $12 million to settle allegations of improper compensation

Feds say CNY hearing practice used unlicensed staff to test customers

Olympus settles federal scope investigation for $85M

U.S. joins false claims lawsuit filed against Sutter Health

Lee Health faced with federal whistleblower lawsuit for alleged Medicare fraud

Regulatory News

CMS Update

From the OIG

In the Federal Register

CMS Transmittals

Acronym Library

Product Features

The First Information Is Almost Always Wrong

Health Care Privacy Compliance Handbook, Second Edition

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Digital transformation demands a whole new level oversight to avoid healthcare fraud

On December 13, 2018, Healthcare Finance reported, “The federal government estimates that over $36 billion in improper fee-for-service Medicare payments have been racked up and the industry overall is wrought with fraud and abuse. Part of it is the nature of the business, said Paul H. Westfall, Washington Counsel for the American Medical Association. It's a very high-transaction and high-volume sector that also carries very fragmented delivery, payment and legal systems. So there is a lot that could potentially not get caught.”

 

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HIPAA penalties for failure to cut off access to former employee

On December 12, 2018, The National Law Review reported, “It has been a busy few weeks for HIPAA enforcement. On Tuesday, the Office for Civil Rights announced its third resolution of a HIPAA breach in as many weeks. In this latest matter, OCR announced that Pagosa Springs Medical Center (PSMC), a critical access hospital in Colorado, has agreed to both pay $111,400 to the Office for Civil Rights (OCR) as well as adopt a comprehensive, two-year corrective action plan (CAP) to address and settle potential HIPAA violations.”

 

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Coordinated Health, CEO pay $12.5M to resolve fraud allegations

On December 12, 2018, HealthLeaders reported, “Coordinated Health Holding Company, LLC and its founder and CEO Emil DiIorio, MD, will pay $12.5 million to resolve allegations that the health system improperly billed Medicare and other government-sponsored health plans for orthopedic surgeries, the Department of Justice said.”

 

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Kingwood resident indicted in connection with more than $4M in health care fraud

On December 12, 2018, Houston Chronicle reported, “A grand jury in Tulsa, Okla. indicted Kingwood resident and physician Jerry Keepers along with two other men in connection with an alleged conspiracy to commit $4.7 million in health care fraud.

 

“Keepers, named as a defendant in the indictment is charged with soliciting and receiving over $860,000 in illegal bribe and kickback payments from Tulsa residents Christopher Parks and Gary Lee, who is also a physician.”

 

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Thomson businesswoman convicted of fraud

On December 12, 2018, The Augusta Chronicle reported, “Detra Wiley Pate, owner and CEO of Southern Respiratory LLC was found guilty on 33 counts, including health care fraud, conspiracy to commit health care fraud and aggravated identity theft for crimes dating back to 2014, according to a news release from the U.S. attorney’s office.”

 

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Rich and on the run: Doctors flee country amid fraud, opioid crackdown

On December 12, 2018, The Detroit News reported, “More than a dozen doctors and medical professionals charged with federal crimes locally have fled the country in recent years amid a federal crackdown on illegal opioid use and health care fraud.”

 

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Aurora to pay $12 million to settle allegations of improper compensation

On December 11, 2018, WBAY.com reported, “Aurora Health Care, Inc. has agreed to pay $12 million to the United States and State of Wisconsin to settle allegations it submitted claims to Medicare and Medicaid in violation of federal law.

 

“The United States Attorney's Office for the Eastern District of Wisconsin says Aurora allegedly violated the False Claims Act in violation of the Stark Law.”

 

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Feds say CNY hearing practice used unlicensed staff to test customers

On December 11, 2018, Syracuse.com reported, “A Central New York audiology practice will pay $566,263 to settle charges it provided services by unlicensed employees and offered free turkeys and other improper inducements to lure customers.

 

“The U.S. Attorney's Office announced the settlement today with Oviatt Hearing and Balance LLC, which has offices in Syracuse, Camillus, Manlius and Oswego.”

 

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Olympus settles federal scope investigation for $85M

On December 11, 2018, Becker’s Hospital Review reported, “Olympus Medical Systems Corp. will pay $85 million to settle federal charges alleging it failed to file adverse event reports regarding bacterial infections linked to its duodenoscopes and continued to sell the devices despite infection risks.

 

“Olympus Medical Systems, a subsidiary of Olympus Corp., and a former senior executive pleaded guilty to distributing misbranded medical devices, according to the DOJ.”

 

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U.S. joins false claims lawsuit filed against Sutter Health

On December 11, 2018, SFGate reported, “The U.S. Department of Justice announced today it will become a party in a whistleblower lawsuit filed in federal court in San Francisco against Sacramento-based Sutter Health LLC and the Palo Alto Medical Foundation.”

According to the government press release, the government “has intervened in a complaint against Sutter Health LLC, a California-based healthcare services provider, and an affiliated entity, Palo Alto Medical Foundation, (collectively 'Sutter') that alleges that Sutter violated the False Claims Act by submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans, the Justice Department announced today. Sutter Health is headquartered in Sacramento, California.”

 

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DOJ Press Release

 

 

Lee Health faced with federal whistleblower lawsuit for alleged Medicare fraud

On December 10, 2018, News-Press reported, “A former Lee Health auditor claims in a federal lawsuit that the public hospital system defrauded Medicare and Medicaid by inflating certain physician bills in the hopes of getting more referrals to its hospitals and clinics.”

 

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Join us for the Managed Care Compliance Conference | January 27-30 in Lake Buena Vista, FL | Learn More >Join us for the Managed Care Compliance Conference | January 27-30 in Lake Buena Vista, FL | Learn More >

 

CMS Update

 

2019 Medicare Part D Opioid Policies: Training Materials

CMS will implement new opioid policies for Medicare drug plans on January 1. The new policies include:

  • Improved safety alerts when patients fill opioid prescriptions at the pharmacy
  • Drug management programs for patients at-risk for misuse or abuse of opioids or other drugs

CMS posted new training materials, including slide decks and tip sheets for:

CMS also recently released an MLN Matters® Article: A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019. Visit the Reducing Opioid Misuse webpage for more information on CMS’ overall strategy.

 

 

 

Provider Compliance - Bill Correctly for Device Replacement Procedures — Reminder

In a September 2017 report, the Office of the Inspector General (OIG) determined that Medicare paid for many device replacement procedures incorrectly. Hospitals are required to use condition codes 49 or 50 on claims for device replacement procedures resulting from a recall or premature failure (whether the device is provided at no cost or with a credit).

 

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

 

The First Information Is Almost Always Wrong

 

Learn More

 

 

Health Care Privacy Compliance Handbook, Second Edition

 

Learn More

 

Are you and your board compliance ready? | Get the knowledge and tools you need at the Board & Audit Committee Compliance Conference | Learn more >Are you and your board compliance ready? | Get the knowledge and tools you need at the Board & Audit Committee Compliance Conference | 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.