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New York DOJ Chiropractor Arrest

October 8th, 2020 by

new york chiropractor arrestBy: Zach Simpson

Earlier this week a complaint was unsealed in federal court in the case of The United States of America v. Joseph Stephan that charged Stephan, who is a chiropractor, in New York with violations of 18 U.S.C. § 1347 (health care fraud) for submitting false claims to the U.S. Department of Labor (DOL) Office of Workers Compensation Program (OWCP) for services that were not actually rendered or were up-coded based on an undercover investigation.

Specifically, the complaint states that CPT code 99204 is a code used to identify an office or other outpatient visit for the evaluation and management of a new patient, which requires three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. The description of CPT code 99204 indicates that: (a) usually, the presenting problem(s) are of moderate to high severity; and (b) typically, 45 minutes are spent face-to-face with the patient and/or family.
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$20M PLEA: DME Spider Web of Regulatory Enforcement Catches Another

September 28th, 2020 by

By: Michael Silverman

2019’s crackdown on use of improper (tele)marketing and telemedicine in the durable medical equipment industry – aptly named “Operation Brace Yourself” – continues to unfold as we head into the last quarter of 2020.

The latest pertinent Department of Justice press release, criminal information and guilty plea informs that a chiropractor in Florida recently pled guilty to one count of conspiracy to commit health care fraud surrounding his involvement in companies improperly billing Medicare (and other federally funded health care programs) for durable medical equipment.

This individual admitted that he and his co-conspirators received more than $10,000,000 in payments after fraudulently billing more than $20,000,000 for durable medical equipment through several different companies. read more

OIG’s Audit found Medicare Contractors Were Not Consistent in How They Reviewed Extrapolated Overpayments in the Provider Appeals Process

September 1st, 2020 by

oig auditBy: Karina P. Gonzalez

When an overpayment is identified in Medicare Part A or B claims, providers can contest the overpayment amount by using the Medicare administrative appeals process.  Because of the large difference between overpayment amount in a sample from an extrapolated amount, the OIG states that it is critical for the review process during an appeal to be fair and consistent. In the first and second levels of Medicare appeals (redetermination and reconsideration) extrapolated overpayments are reviewed by MAC (Medicare Administrative Contractors) and by QICs (Qualified Independent Contractors).

The OIG audit was to make sure that the MACs and the QICs reviewed the appealed extrapolated overpayments consistently and in compliance with CMS requirements.

What OIG found was that CMS did not always provide sufficient guidance and oversight to ensure that these reviews were performed in a consistent manner.  The most significant inconsistency identified was the use of a type of simulation testing that was performed only by a subset of contractors.  The test was associated with at least $42 million in extrapolated overpayments that were overturned in fiscal years 2017 and 2018. read more

DOJ Makes Third Revision to its Compliance Guidance in as Many Years

July 6th, 2020 by

corporate healthcare complianceBy: Jacqueline Bain

In the beginning of June, 2020, the Department of Justice (“DOJ”) revised its Evaluation of Corporate Compliance Programs Guidance Document. The Document is designed to assist prosecutors in making informed decisions as to whether, and to what extent, the company’s compliance program is effective for purposes of determining, when a compliance violation has occurred, the appropriate form of any resolution or prosecution and monetary penalty. It also guides a prosecutor as to the company’s compliance obligations contained in any criminal resolution. The Document has been revised on three occasions since 2017, telegraphing the DOJ’s intent to prosecute those businesses without compliance plans, or without effective compliance plans, more harshly than those taking steps to identify and remedy risks. 

A healthcare business’ failure to have in place a compliance program designed to detect and respond to potential fraud and security risks places it at a serious risk of civil and criminal liability. When a compliance issue is investigated, charged and resolved, DOJ prosecutors are instructed to consider whether the business has invested in and improved its corporate compliance program and internal controls systems. They must also determine whether those improvements have been tested to demonstrate that they would prevent or detect similar misconduct in the future. According to the DOJ, there are three fundamental questions that a prosecutor should ask when determining whether a business’ compliance plan is sound:  read more

Federal Agencies Scrutinizing Home Healthcare Fraud & Kickbacks

October 11th, 2019 by
home healthcare, HHS, heathcare

checking mans blood pressure

By Karina P. Gonzalez

Federal agencies are continuing to target home healthcare industry fraud in “hot zone areas.”

Recently, the U.S. Department of Health and Human Services Office of Inspector General (HHS) released its report. It identified Florida, Texas and select areas in Southern California and the Midwest as areas where home healthcare fraud is more likely to occur. It is obvious that the watch dog agencies will continue to monitor home healthcare spending in these hot zones.

HHS found that a home health agency incorrectly billed Medicare and did not comply with Medicare Billing requirements for beneficiaries that were not homebound and for others that did not require skilled services at all.

In August and September 2018, physicians and the owner of a home health agency were each sentenced on multiple counts of conspiracy and healthcare fraud and ordered to pay $6.5 million in restitution. One physician was sentenced to 132 months in prison following trial. A physician who pled guilty was sentenced to 27 months in prison following a guilty plea. The home health agency owner was sentenced to 42 months in prison.   The defendants paid and received kickbacks in exchange for patients and billed Medicare more than $8.9 million for services that were medically unnecessary, never provided, and/or not otherwise reimbursable. Additionally, certain defendants provided prescriptions for opioid medications to induce patient participation in the scheme.

In September 2018, the co-owner and administrator of a home health agency was sentenced to 24 months in prison, ordered to pay over $2.2 million in restitution, and ordered to forfeit over $1.1 million. The co-owners participated in a home healthcare fraud conspiracy that resulted in Medicare paying at least $2.2 million on false and fraudulent claims. The owners and their co-conspirators paid kickbacks to doctors and patient recruiters in exchange for patient referrals, billed Medicare for services that were medically unnecessary, and caused patient files to be falsified to justify the fraudulent billing.

Back in February 2018, the owner of more than twenty home health agencies was sentenced to 240 months in prison and ordered to pay $66.4 million in restitution, jointly and severally with his co-defendants, after pleading guilty to one count of conspiracy to commit health care fraud and wire fraud. A patient recruiter for the home health agencies, who also owned a medical clinic and two home health agencies of her own, was sentenced to 180 months in prison. Another patient recruiter, who also was the owner of two home health agencies, was sentenced to 115 months in prison. These conspirators paid illegal bribes and kickbacks to patient recruiters in return for the referral of Medicare beneficiaries many of whom did not need or qualify for home health services.  Medicare paid approximately $66 million on those claims.

Illegal kickbacks in exchange for referrals of Medicare beneficiaries, lack of medical necessity for home health services, failing to meet the guidelines, fraudulent billing, billing for services beneficiaries did not receive and fraudulent documentation continues to plague the home healthcare industry.

 

Operation Double Helix – Unprecedented Genetic Testing Fraud

October 10th, 2019 by

By: Karina P. Gonzalez 

According to the Department of Justice (DOJ) genetic testing is the next frontier for healthcare fraud.

In a fraudulent operation that the Department of Justice calls, “unprecedented”, elderly or disabled patients nationwide were lured into providing their DNA for testing in a widespread genetic testing fraud scheme powered by a large telemarketing network. The doctors involved were paid to write orders prescribing the testing without any patient interaction or with only a brief telephone conversation. read more

Medicare Enforcement: CMS Has Expanded Its Ability to Revoke or Deny Provider Enrollment

September 10th, 2019 by

medicare enforcementBy: Karina Gonzalez

A Final Rule recently issued by CMS will require Medicare, Medicaid, and CHIP (Children’s Health Insurance Program) providers and suppliers to disclose current and previous affiliations (direct or indirect) with a provider or supplier that: (1)  has uncollected debt; (2) has been or is excluded by the OIG (Office of Inspector General) from Medicare, Medicaid or CHIP, or (3) has had its billing privileges with either of these three programs denied or revoked. Such provider affiliations may lead to enrollment being denied if it poses a risk to fraud, waste or abuse. read more

State Patient Brokering Act Cases to Throw out Legal Advice as Defense

October 9th, 2018 by

palm beach county task forceBy: Jeff Cohen

There are two criminal cases pending in Palm Beach County that threaten to put a bullet in the heart of healthcare professionals and businesses and also the law practices that advise them.  Both State v. Simeone and State v. Kigar have a motion from the State pending before them to block any testimony that the defendants received legal advice concerning a contract entered into by an addiction treatment facility and a sober home.  The State alleges that the contract violates the state Patient Brokering Act (PBA) because it was essentially a ruse whereby the addiction treatment facility was just paying for the sober home to refer patients.  Now the State wants to make sure that the entire issue of the defendants being advised by counsel never sees the light of day.

How is this possible?  How can it be that a client can seek legal counsel, get advise (and presumably follow it), and then be blocked from presenting that evidence?  The State argues that the PBA has no wording that requires them to prove intent.  And if intent isn’t an element to be proven, the argument goes, then evidence of the client intending not to violate the law by getting advice beforehand is inadmissible!   read more

Anti-Kickback Statute and Healthcare Marketing: 3 Legal Considerations

September 6th, 2018 by

healthcare marketingBy: Matt Fischer

Healthcare marketing arrangements that violate the Anti-Kickback Statute (AKS) can lead to serious financial and criminal consequences.  Understanding the types of marketing arrangements that courts have found to be in violation of the statute and the potential implications are critical for marketers to know in order to operate in the healthcare industry.

Under the AKS, it is a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce referrals of items or services reimbursable by the Federal health care programs.  Where remuneration is paid purposefully to induce referrals of items or services paid for by a Federal health care program, the AKS is violated.  By its terms, the AKS ascribes criminal liability to parties on both sides of an impermissible transaction.  An example of a highly scrutinized arrangement involves percentage compensation.  For regulators, percentage compensation arrangements provide financial incentives that may encourage overutilization and increase program costs.

Here are 3 important things to know: read more

The Case Against Cloning (Medical Records)

August 10th, 2018 by

medical records cloningBy: Jacqueline Bain

The transition from paper medical records to electronic medical records has brought with it many conveniences and some unintended consequences. One example of an unintended consequence is cloning in the medical record. Cloning is copying and pasting previously recorded information from a prior patient note into a new patient note.

Providing quality medical care is only one part of the job. Appropriately documenting that care in order to be paid for your efforts is another. And while medical professionals are trained at length to provide care, hardly any are aware of the potential pitfalls associated with improper documentation.

In late 2015, CMS advised that cloning “is a problem in health care institutions that is not broadly addressed.” CMS specified that cloning records may indicate fraud, waste and abuse in inquiries and audits and that each part of a “medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter.” read more