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Compliance National & Local News

The Office of Inspector General and other government agencies continue to actively investigate areas of reported non-compliance. Being aware of government auditing trends is beneficial in determining areas for the OU Billing Compliance Office to focus on during in-house audits. The findings of government investigations are published on-line for public viewing.

National News

Medicare Fraud Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing
Published on line 05/14/2013
Announced today, a nationwide takedown by Medicare Fraud Strike Force operations in eight cities has resulted in charges against 89 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $223 million in false billings. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, primarily home health care, but also mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services. 

This coordinated takedown was the sixth national Medicare fraud takedown in Strike Force history.  In total, almost 600 individuals have been charged in connection with schemes involving almost $2 billion in fraudulent billings in these national takedown operations alone. The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT). Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,500 defendants who collectively have falsely billed the Medicare program for more than $5 billion.  In addition, CMS, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The joint Department of Justice and HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing.  Approximately 400 law enforcement agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units and other state and local law enforcement agencies participated in the takedown. 

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and often never provided.  In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent billing to Medicare for services that were medically unnecessary or never performed.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $223 million in fraudulent billing.

The cases announced today are being prosecuted and investigated by Medicare Fraud Strike Force teams comprised of attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorney’s Offices for the Southern District of Florida, the Eastern District of Michigan, the Eastern District of New York, the Southern District of Texas, the Central District of California, the Middle District of Louisiana; the Northern District of Illinois, and the Middle District of Florida; and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units.

To learn more about HEAT, go to: www.stopmedicarefraud.gov

To access the entire Department of Justice press release, please click on HEAT Taskforce

To read more about the Office of Inspector General fraud actions, please click on OIG Criminal & Civil Enforcement

Medicare Concerned EHRs Lead to Upcoding
Published on line 05/13/2013
The accuracy of provider documentation has been scrutinized for years, but a relatively new focus of complaints involves how providers use features of electronic health record systems to support their claims. Concerns that providers are taking advantage of EHR automation to bill higher-level services — intentionally or not were discussed during a May 3 forum at the Centers for Medicare & Medicaid Services headquarters.

Federal lawmakers and CMS officials have encouraged providers and hospitals to adopt EHRs by offering financial incentives and threatening eventual cuts to Medicare payments. Health information technology can provide clinical support, allow sharing of records across care settings and offer other functions, such as drug formulary checks. EHRs are viewed as an asset in new care and payment models.

But the technology can be a double-edged sword. CMS lately has become concerned about the unintended consequences of EHR adoption. Auditors and lawmakers have suggested that recent increases in the rates at which doctors bill costlier, higher-level services could be attributable to the enhanced billing capabilities provided by EHRs.  Jonathan Blum, CMS deputy administrator and director of the agency's Center for Medicare, stressed that the program's own data don't yet point to evidence of such a correlation, but he noted that CMS was looking into the matter.

 The real problem with EHRs lies in how providers have had to incorporate them into their practices. The task has been frustrating and difficult, because providers find costly systems unhelpful as they painstakingly navigate through various prompts to complete simple tasks. Providers taking part in a Medicare or Medicaid EHR incentive program since 2011 also must follow criteria to demonstrate meaningful use of paperless systems, which has had unintended consequences, he said.

Medical records once were designed only for writing findings and decision-making processes for doctors' personal reference and communication with other physicians. Over time, the records' purpose has expanded as a tool for dealing with coding, billing, compensation, compliance and litigation.  Complaints from users about the frustrations of EHRs notwithstanding, concerns from payers about increases in billing intensity don't appear to be waning.

The Medicare administration convened the May 3 session to gather more information about the issue. CMS' Blum said his agency recognizes that its own coding guidelines and payment policies might be part of the problem. Medicare is considering revisions as the health system shifts to one relying less on paper records.  But some see recent changes in billing patterns not as a sign of unwarranted upcoding enabled by paperless systems, but as a legitimate accounting of services.

Before widespread use of EHRs in clinical practices, doctors and other health professionals often were concerned about possible accusations of fraud and abuse if billing codes were not deemed supportable by the medical documentation.   By taking some of the guesswork out of the process, EHRs may be enabling more physicians to bill more accurately.

For additional information, please click on any of the links below for supplemental reports from the May 3, 2013 CMS forum.

CMS May 3 2013 Meeting

AAMC Coding Session May 3 2013

AAHC Coding Session May 3 2013

FAH Coding Session May 3 2013

OIG Investigating Cigna Medicare Advantage Plan for Overbilling
Published on line 05/13/2013
Cigna Healthcare of Arizona, a subsidiary of national insurer Cigna providing Medicare Advantage plans, overbilled Medicare by about $28 million in 2007, according to a new report released last week from the U.S. Department of Health & Human Services Office of Inspector General.

The OIG determined that Cigna submitted diagnoses to HHS for its risk score calculations that didn't always comply with federal requirements. Of the 100 beneficiaries in the sample OIG analyzed for the report, 40 had invalid risk scores because either the documentation didn't support the associated diagnosis or the diagnosis was unconfirmed.

Because Cigna's contracts require its providers submit accurate claims, the insurer assumed all providers were submitting accurate diagnoses as well. But the OIG said providers often report incorrect diagnoses or report diagnoses for conditions that didn't exist when providers treated the beneficiaries.

Based on its investigation, the OIG said Cigna must repay at least $151,000 in improper charges. The federal auditor also recommended that HHS conduct a more in-depth review of the disputed payments. Also, CIGNA needs to bring its "significant error rate" into compliance with federal rules, the report said.

"For one beneficiary, Cigna submitted the diagnosis code for 'congestive heart failure, unspecified,' " the report said. "However, the documentation that Cigna provided indicated that the beneficiary visited the physician because of knee pain. The documentation did not support the diagnosis of congestive heart failure."

Cigna, however, disagreed with the OIG's findings. In a written response to the report, Cigna said the OIG didn't properly account for frequent disparities in charges shown in claims data and in medical records. What's more, the OIG should have analyzed more medical records in its sample and taken a different statistical approach, both of which would have resulted in Cigna owing a total of just $440,000.

HHS will review the report and decide whether to implement the OIG's recommendations or take separate action. Cigna can appeal the report's findings. To read the entire report, please click on Cigna Overbilling

CMS Overpaid Medicare Advantage Plans by $5.1 Billion
Published on line 05/13/2013
Insurers that sell Medicare Advantage plans received as much as $5.1 billion in overpayments between 2010 and 2012, according to a new report from the Government Accountability Office. The problem, federal government auditors say, is the Medicare Advantage program is structured so that it pays insurers more for members with certain medical diagnoses. So Medicare Advantage plans have been classifying their members as being sicker than members in traditional fee-for-service programs.

Moreover, the Centers for Medicare & Medicaid Services didn't appropriately adjust Medicare Advantage members' risk scores to account for the insurers' differences in treatment and diagnostic coding. But the America's Health Insurance Plans pushed back on the GAO's findings. A spokesperson for the organization stated report doesn't take into account what plans are doing to identify beneficiaries who have potential health risks and then putting into place programs and services to make sure patients are getting the care they need. What's more, Medicare Advantage plans go out of their way to make sure they know patients' health risks so they can intervene early and avoid complications down the line, the organization added.

The GAO report comes amid fighting between the insurance industry and the federal government over recently proposed cuts to Medicare Advantage plans. CMS wants to reduce payments per person for Medicare Advantage plans by more than 2 percent in 2014, which could lead to insurers losing a total of $11 billion. To read the entire report, please click on CMS Overpayment

University of Chicago Settles EMTALA Case
Published on line 01/09/13
University of Chicago Medical Center (UCMC), IL, agreed to pay $50,000 to resolve its liability for Civil Monetary Penalties under the patient dumping statute. The OIG alleged that UCMC failed to provide appropriate medical screening and stabilizing treatment within its capabilities to a male patient who presented to their emergency department complaining of severe jaw pain as a result of a physical assault.

According to OIG, the elderly man arrived at the University of Chicago Medical Center emergency department (ED) in an ambulance in 2009. He was complaining of severe jaw pain because of a physical assault. The patient's information was not entered into the ED log. He did not receive an appropriate medical screening or stabilizing treatment and died in the waiting room.

EMTALA requires hospitals with emergency rooms to conduct medical screening exams and stabilize patients with emergency medical conditions regardless of their ability to pay. Patients can be transferred only if the hospital lacks the staff or equipment to treat them. The civil monetary penalty law that bans patient dumping under EMTALA allows for a maximum $50,000 penalty per violation, which is the amount of the fine by the OIG.

In a statement about the man’s 2009 death, University of Chicago Medical Center conducted an investigation immediately afterward to determine whether every aspect of the care and coordination in the emergency department was appropriate. The investigation at that time found that proper policies and procedures were in place but staff members may not have followed the protocol. Appropriate disciplinary actions were taken. Since then, the University of Chicago Medical Center worked closely with CMS and the state of Illinois to advance its compliance with regulatory and patient care standards.

For more information about this article, please click on UCMC Case

To read about more cases such as this, please click on EMTALA Cases 2012

For more information about the Emergency Medical Treatment & Labor Act, please click on EMTALA

Local News

Owner of Oklahoma Clinics Charged with Medicaid Fraud
Published 05/03/13
Attorney General Scott Pruitt’s Medicaid Fraud Control has filed charges against the owner of medical clinics in Del City and Shawnee. If convicted, the owner faces a possible maximum sentence of three years per count and/or fines of up to $183,745.

Deanna Williams, 49, owner of Fast Care Medical Clinics, was charged with two counts of Medicaid fraud in Oklahoma County District Court for allegedly sending the Oklahoma Health Care Authority (OHCA) more than 940 duplicate claims for payments between January and December of 2011. During the investigation, investigators learned that Williams was sending claims to OHCA through the agency’s secure website while also submitting the same claims through her other company, North West Medical Billing.

The Medicaid Fraud Control Unit is the only Oklahoma law enforcement agency dedicated to the investigation and prosecution of Medicaid fraud. The Unit helps raise awareness as well as investigates and prosecutes provider fraud and abuse of residents in Medicaid funded nursing homes.

For more information, please click on Medicaid Fraud

Oklahoma Providers and a Hospital Charged with Healthcare Fraud
Published 06-27-12
According to FBI and Department of Justice (DOJ) reports, three Oklahoma providers and a hospital have been accused of healthcare fraud. Two of the providers have already been convicted, while the third has not according to the DOJ press releases.

The first provider was from Tecumseh, and ordered to serve 51 months in prison. The provider must also pay over $4.6 million in restitution for healthcare fraud in association with the sales of prosthetics. He must then serve two years of supervised release upon his release from prison, serve 104 hours of community service, and pay $4,667,076.27 in restitution. The provider billed Medicare and Medicaid for beneficiaries who did not have a prescription for the prosthetics from a licensed physician or other qualified health care provider. Instead, Faulkner submitted physician names and identification numbers to Medicare and Medicaid even though many of those physicians had never treated the patients or prescribed the prosthetic limbs. It was also alleged that Faulkner submitted claims to Medicare and Medicaid for expensive, computerized prosthetic limbs, when the beneficiaries actually received less sophisticated prosthetics or none at all. To read the entire article, please click on Tecumseh Provider.

The second provider is a dentist from Oklahoma City, that has been charged with committing health care fraud while under the employment of an area dental clinic. The information alleges that from July 12, 2007 through December 31, 2010, the provider engaged in a scheme to defraud Medicaid by submitting claims for dental services that she did not provide. Specifically, it is alleged that the provider recorded in the patient’s treatment notes that she had placed dental restorations on certain teeth when, in fact, she had not treated the teeth at all. It is also alleged that on other teeth, the provider recorded that she had placed dental restorations on more surfaces of the tooth than she had, in fact, restored or recorded that she had placed a dental restoration on the tooth when, in fact, she had placed on the tooth a type of treatment that is non-reimbursable by Medicaid. Relying upon the provider's treatment notes, the dental clinic submitted claims for reimbursement to Medicaid and paid the provider a percentage of those reimbursements. If convicted, the provider faces up to 10 years in prison and a $250,000 fine. To read the entire article, please click on OKC Dentist.

The third provider and a Harmon county hospital have agreed to pay $1,550,000 to settle claims of health care fraud of the Medicare and Medicaid programs. This suit was brought under the qui tam or whistleblower , provisions of the federal False Claims Act (FCA) and the Oklahoma Medicaid False Claims Act (OMFCA). The whistleblower was a former hospital administrator for Harmon county. The United States and State of Oklahoma alleged that from July 1, 2001, through May 30, 2008, both hospital and the provider violated the FCA and the OMFCA by submitting claims, or causing claims to be submitted, to the Medicare and Medicaid programs that violated the federal “Stark” regulations and Anti-Kickback Statute. Specifically, the government alleged that there was a prohibited contractual relationship between the hospital and the provider resulting in excessive remuneration which was not commercially reasonable in the absence of health care referrals and that the hospital and provider made false certifications that the Medicare and Medicaid claims they submitted were in compliance with federal and state regulations. The alleged improper remuneration included, but was not limited to, free rent of office space, free billing and staff personnel, reimbursement of uncollected accounts receivable, duplicative per encounter payments for emergency room services, and improper payment of locum tenens physician services. In the settlement, the hospital agreed to pay $550,000 and the provider agreed to pay $1,000,000 to resolve the claims. In addition, both have entered into five year corporate integrity agreements with the United States Department of Health and Human Services Office of the Inspector General which requires additional regulatory compliance reporting and monitoring. To read the entire article, please click on OK Hospital Provider.

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