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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.
Fraud Case Against the University of Medicine and Dentistry of New Jersey Finally Concluded
Published on line 06/17/2009
The University of Medicine and Dentistry of New Jersey (UMDNJ) fraud case was concluded on June 10, 2009 as reported by the U.S. Department of Justice (DOJ). The final settlement ends the criminal and civil case which began in 2005 and was brought about by a whistleblower.
From 1993 to 2004, UMDNJ’s University Hospital submitted claims to Medicaid for outpatient physician services that were also being billed by doctors working in the hospital’s outpatient centers. By submitting duplicate claims for payment, University Hospital effectively doubled billed the government’s Medicaid program. The University was charged
with deliberately double-billing both Medicaid and Medicare by nearly $5 million.
The billing issues at UMDNJ were complex and the hospital and its doctors were constantly at odds with each other over the matter. More than a decade earlier, memos show, university officials were cautioned numerous times about the billing problems -- warnings that were repeatedly ignored as both sides continued to bill for the same services
The faculty physicians based validity of their billing on a 1984 court ruling that the faculty members' claim that only they could bill for patient services. However, university administrators insisted the doctors were hospital employees and only the hospital could bill. As a result, both sides billed Medicaid and Medicare millions of dollars for the same patient services.
UMDNJ agreed to reimburse to the federal and state governments a total of $4.9 million (of which $2.065 million has already been paid to the government). The $4.9 million represents the amount of willful double-billing known to date; any other amounts determined in the investigation to have been received unlawfully or in error by UMDNJ must also be reimbursed. After the university paid back the money it had overbilled, it still had to resolve the civil liabilities it faced with the Justice Department and the state Department of Health and Human Services. The school agreed to pay an additional $2 million.
In addition to the monetary settlement, The University was appointed a federal monitor with wide
discretion and powers to enforce and ensure compliance with the terms of the settlement. The DOJ
made clear that the settlement does not protect or absolve any individuals who may have been involved in criminal conduct. The criminal investigation is continuing and charges will be brought as necessary and appropriate.
"Today's settlement demonstrates that the Department of Justice will not tolerate fraud on our Medicaid programs, which were created to serve our nation's low-income families, children and seniors," said Tony West, assistant attorney general for the Justice Department's Civil Division.
"We still have the right to pursue individuals who were responsible," he said
To access the Department of Justice report, please click on UMDNJ Press Release 06/2009. There is also a previous press release from the DOJ for the initial fraud report. To access the information, please click on UMDNJ Press Release 12/2005
Medical Center Pays $2.5 Million For Allegations of Improper Claims
Published on line 06/08/2009
Queen's Medical Center ("QMC") of Honolulu, Hawaii has paid a total of $2.5 million to settle two lawsuits alleging that QMC over billed the Medicare program, the State of Hawaii Medicaid program, and TRICARE, the federal health benefits program for military dependents. The settlement grew out of civil "whistleblower" suits brought in federal and state court
under the federal and State of Hawaii False Claims Acts.
Edward H. Kubo, Jr., United States Attorney for the District of Hawaii, said that
QMC submitted false bills for pharmaceuticals dispensed at the hospital, and billed federal programs for services provided by residents without the level of supervision required by federal rules. According to the settlement agreement signed on April 27, 2009, the federal and state governments contended that:
- (1) from September 8, 1999 through October 28, 2002, QMC submitted false claims to Medicare, Medicaid and TRICARE seeking payment for the dispensation of anti-psychotic medications allegedly ordered by a psychiatrist, whereas the medications were actually ordered by non-psychiatrist physicians without the prior knowledge of a psychiatrist; and
- (2) from July 1, 1999 through June 30, 2006, QMC wrongfully submitted claims to Medicare, Medicaid, and TRICARE for services it represented were provided by teaching physicians when QMC did not have the documentary evidence necessary to demonstrate that the teaching physicians were involved in the services to the degree necessary to support payment of the claims.
“Settlements such as this demonstrate yet again that submitting false claims to federal health care programs artificially raises health care costs and in turn takes from those who depend on these government medical programs,” said Glenn R. Ferry, Special Agent in Charge for the Los Angeles Region of the Office of Inspector General, U.S. Department of Health and Human Services. “My agency, working with our federal and state law enforcement partners, will continue to aggressively investigate and prosecute such fraud.”
To access the complete information, please click on QMC Settlement
Attorney General and HHS Secretary Announce New Interagency Health Care Fraud Prevention and Enforcement Action Team
Published on line 05/26/2009
The Attorney General and Health & Human Services (HHS) Secretary
announced the creation of a new interagency effort, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to combat Medicare fraud on May 20, 2009.
"With this announcement, we raise the stakes on health care fraud by launching a new effort with increased tools, resources and a sustained focus by senior-level leadership,” said Attorney General Holder. “Every year we lose tens of billions of dollars in Medicare and Medicaid funds to fraud. Those billions represent health care dollars that could be spent on medicine, elder care or emergency room visits, but instead are wasted on greed. This is unacceptable, and the Justice Department is committed to working with the Department of Health and Human Services to eradicate it.”
The HEAT team will include senior officials from DOJ and HHS who will build upon and strengthen existing programs to combat fraud while also investing new resources and technology to prevent fraud, waste and abuse before it happens. Prevention is critical to reforming the system and the HEAT team will also focus critical resources on preventing fraud from occurring in the first place.
Fraud prevention efforts are also strengthened in President Obama’s proposed Fiscal Year 2010 budget. The President’s budget invests $311 million -- a 50 percent increase from 2009 funding -- to strengthen program integrity activities within the Medicare and Medicaid programs. Combined, the anti-fraud efforts in the President’s budget could save $2.7 billion over five years by improving oversight and stopping fraud in the Medicare and Medicaid programs.
To access the complete details of the HHS press release, please click on HEAT team information
Pharmaceutical Company Charged with Marketing Drugs for Unapproved Pediatric Use and Paid Kickbacks to Providers
Published on line 05/26/2009
The Department of Justice (DOJ) has filed a complaint against a New York pharmaceutical company for alleged False Claims Act violations arising from the company's marketing the drugs Celexa and Lexapro for unapproved pediatric use and for paying kickbacks to induce physicians to prescribe the drugs.
In February, the DOJ unsealed a whistleblower complaint that alleged the company violated the False Claims Act and paid kickbacks to physicians to get them to prescribe the drugs. The company induced physicians by providing them with illegal remuneration such as cash payments disguised as grants or consulting fees, expensive meals or entertainment, which violate the anti-kickback statute. This caused thousands of false and fraudulent claims to be submitted to federal health care programs.
In response to the allegations, the pharmaceutical company has set aside $170 million while in discussions with the DOJ about the investigation into the alleged kickbacks paid to physicians, the company said in a prepared statement. Accordingly, until the investigation is resolved, there can be no assurance that the amount reserved by the company will be sufficient and that a larger amount will not be required.
To read complete details of the complaint, please click on DOJ Press Release
Oncologist Charged with Health Care Fraud
Published on line 04/08/2009
A Virginia Beach doctor was indicted in federal court on charges of defrauding government health care programs. On April 3, 2009, the doctor
was charged by a Norfolk federal grand jury in a forty-five count indictment with health care fraud, making false statements relating to health care matters, and alteration of records to obstruct an investigation. As a result of these fraudulent claims, Poulin obtained over $850,000 in health care benefit payments from Medicare and Tricare to which he was not entitled.
The indictment alleges
between January 2006 through August 2008, the doctor fraudulently billed Medicare and Tricare for a greater amount (increased units) of chemotherapy drugs than he actually administered to patients and for office visits that involved a more thorough medical examination than he actually rendered to patients (up-coding). The doctor
falsified, and directed members of his staff to falsify, patient medical records subpoenaed during the investigation of this case.
The doctor also
diagnosed patients with renal disease in order to bill Medicare and Tricare for the administration of Procrit although he knew administering the drug to these patients was not medically reasonable. However, the diagnosis was made to support medical necessity of the services.
To read the complete DOJ press release, please click on Oncologist Charged
Cardiologist Settles False Claims Act Case
Published on line 04/08/2009
A Kansas cardiologist and his practice group, have agreed to pay the United States$1.3 million to settle claims that the physician and his group violated the False Claims Act (FCA) between 2001 and 2006,by submitting false claims to Medicare
announced in a press release from the Department of Justice (DOJ) on March 3, 2009. The government stated the two main violations were claims submitted for services not provided and claims submitted without proper documentation.
According to the DOJ, this is the second FCA case the doctor has been charged with. In May 2000, the cardiologist and his medical group agreed to pay more than $1.5million to settle a previous False Claims Act matter. In that case, the government contended that between 1993 and 1998, the doctor billed Medicare for higher levels of services than provided (up-coding), billed twice for the same services (double-billing), and billed for services not provided.
For the recent case and part of the $1.3 million settlement, the cardiologist and his medical group have entered into an Integrity Agreement with the U.S. Department of Health and Human Services, Office of Inspector General. The Integrity Agreement contains measures to ensure compliance with Medicare regulations and policies in the future.
The settlement of the second case was the result of a coordinated effort among the Commercial Litigation Branch of the Justice Department's Civil Division; the U.S. Attorney's Office for the District of Kansas; and the Department of Health and Human Services' Office of Inspector General and Office of Counsel to the Inspector General.
To read the complete DOJ press release, please click on Kansas Cardiologist
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RAC Audits To Resume
Published on line 02/26/2009
February 4, 2009 the parties involved in the protest of the award of the Recovery Audit Contractor(RAC) contracts settled the protests. The settlement means that the stop work order has been lifted and CMS will now continue with the implementation of the RAC program.
Under the program, the four RACs will contract with subcontractors to supplement their efforts. PRGSchultz, Inc. will serve as a subcontractor to HDI, DCS and CGI in regions A, B and D. Viant Payment Systems, Inc. will serve as a subcontractor to Connolly Consulting in region C. Each subcontractor has negotiated different responsibilities in each region, including some claim review.
RAC Permanent Program: Section 302 of the Tax Relief and Health Care Act of 2006 makes the RAC Program permanent and requires the Secretary to expand the program to all 50 states by no later than 2010. See below for a link to the text of this legislation. This web page describes CMS' strategy for expanding from a 3-state demonstration RAC Program to a 50-state permanent RAC Program.
Implementation Strategy: By 2010, CMS plans to have 4 RACs in place. Each RAC will be responsible for identifying overpayment and underpayments in approximately ¼ of the country. The new RAC jurisdictions match the DME MAC jurisdictions. See below for a link to the RAC Jurisdiction Map.
The RAC demonstration program has proven to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments. Additional states will be added to each RAC region in 2009.
To read the complete report, please click on RAC Audit. To view the map, please click on RAC Map.
Physician Found Liable of Medicare Fraud
Published on line 02/25/2009
A federal jury today found a Las Vegas anesthesiologist liable of committing federal health care fraud for submitting over 3,500 false or fraudulent claims to the United States Government between 1999 and 2006 for consultation services not requested or provided, announced Greg Brower, United States Attorney for the District of Nevada. The physician was charged in a civil complaint with violating the federal False Claims Act.
“The Department of Justice in Nevada will continue to pursue physicians who present false claims to the Government,” said U.S. Attorney Brower. “Anyone found violating the False Claims Act, faces triple the proven damages, as well as civil penalties and costs of prosecution.”
The jury found that the physician submitted claims for consultation services that he had not been requested to perform and/or had not performed. In reliance on doctor's false certifications on the claim forms, Medicare paid reimbursements to the doctor totaling approximately $421,000. This amount will automatically be tripled under the False Claims Act, to approximately $1.26 million. Medicare would not have paid such claims had the doctor provided truthful information.
On April 14, 2009, a hearing will be held to determine the amount of civil penalties to be awarded to the United States under the False Claims Act. The Government is requesting between approximately $1 million and $2 million in penalties.
For more details, please click on Physician Fraud
New Pharma Sales Regulations in Washington, D.C.
Published on line 11/7/2008
New regulations took effect on October 1, 2008 for pharmaceutical sales representatives in the District of Columbia. These regulations were in response to the passage of the Safe Rx Amendment Act of 2008 by the District of Columbia Board of Pharmacy.
Effective April 1, 2009, a person must be licensed by the District of Columbia Board of Pharmacy (the “Board”) to engage in pharmaceutical detailing. The “practice of pharmaceutical detailing” is defined as: “the practice by a representative of a pharmaceutical manufacturer or labeler of communicating in person with a licensed health professional, or an employee or representative of a licensed health professional, located in the District of Columbia, for the purpose of selling, providing information about, or in any way promoting a pharmaceutical product.”
The regulations define a “pharmaceutical company” as: “any entity that is engaged in either directly or indirectly, the production, preparation, propagation, compounding, manufacturing, conversion or processing of a drug or biologic product, including any person acting as its agent or representative.”
The regulations provide that a pharmaceutical detailer must complete and submit a detailed application to the Board, satisfy pre-education and ongoing education requirements, comply with the code of ethics described in the regulations, fulfill document retention standards and be subject to penalties for failing to comply with the Act and regulations. The pharmaceutical detailer license expires at the end of February in every even-numbered year and the initial license fee is $175, with a renewal license fee of $165.
In addition, the pharmaceutical detailer is required to comply with the PhRMA Code on Interactions With Healthcare Professionals. If
there is a conflict between the PhRMA Code and the Act and its regulations, the Act and its regulations shall prevail. The pharmaceutical
detailer will be required to complete an affidavit to abide by the regulation code of ethics.
To read the complete District of Columbia municipal regulation for pharmaceutical dealers, click on The Act.
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Updated PhRMA Code to Further Regulate Pharmaceutical Industry
Published on line 11/7/2008
The PhRMA Code regulations were updated recently and enhanced the voluntary Code on relationships with U.S. healthcare professionals. This Code reflects and builds upon the standards and principles set forth in its predecessor, the PhRMA Code on Interactions with Healthcare Professionals that took effect on July 1, 2002. Like the 2002 edition, this Code addresses interactions with respect to marketed products and related pre-launch activities. PhRMA member companies’ relationships with clinical investigators and other individuals and entities as they relate to the clinical research process are addressed in the PhRMA Principles on Conduct of Clinical Trials and Communication of Clinical Trial Results. This updated Code will take effect in January 2009.
The revised code prohibits the distribution of noneducational materials, even those perceived to have minimal value, such as pens and mugs that include a pharmaceutical company's logo. In addition, company sales representatives are prohibited from providing restaurant meals to healthcare professionals, although they may provide occasional meals in conjunction with informational/educational presentations.
Health-system pharmacists welcome the changes to the code and believe that past practices sent the wrong message. "The revised code is a step in the right direction. I don't think it has gone as far as we've gone here at our institution or as far as I think we should go," said Jim Stevenson, PharmD, director of pharmacy at the University of Michigan Health System (UMHS) in Ann Arbor.
In the section of the revised code that addresses speaking and consulting fees, some pharmacists believe that the guidelines are too vague. "There should be a set fee for what the honorarium is. That tends to vary," Russ Lazzaro, RPh, director of pharmacy at Holy Name Hospital in Teaneck, N.J., said. Lazzaro said the honorarium should be a set rate or at least a variable rate based on a speaker's credentials. On the topic of whether providing food influences behavior, Lazzaro said food gives drug reps access to the doctors office. "The office manager controls who sees the doctor."
Among PhRMA members, some large, innovator drug companies publicly endorse the revised marketing code. "We believe that the meaningful Code revisions that have been adopted will address the concerns of our various stakeholders and strengthen the public trust in our industry and help to ensure that the information exchange with healthcare providers continues to be appropriate and ethical," Robert Brown, chief marketing and operations officer for Lilly's U.S. operations, said.
Below are a few questions and answers from the updated PhRMA code:
Q: A field sales representative of Company X provides pizza for the staff of a medical office during lunch time. Is this consistent with the Code?
A: Providing an occasional meal would be consistent with the Code if the sales representative will provide an informational presentation to the medical staff in conjunction with the meal of modest value, so long as the location of the in-office presentation is conducive to scientific or educational communication. Merely dropping off food for the office staff, however, would not be consistent with the Code.
Q: A field sales representative of Company X invites physicians to meet to hear a scientific and educational presentation about a new drug at the café at a nearby bookstore. Lunch is provided by the representative and, following the presentation (which is in small groups), each physician is given a gift certificate for books in the amount of $30. Does this conform to the Code?
A: No. While the presentation may present scientific or educational information, a company field sales representative should not provide even a modest meal to healthcare professionals outside of the office or hospital setting (except under the limited circumstances where the field sales representative attends a company sponsored speaker program to provide logistical support and help monitor compliance with FDA requirements. In addition, an open-ended gift certificate is a cash equivalent. A medical textbook, a book on patient care, or a gift certificate redeemable solely for a medical textbook or book on patient care could be
provided if it is not of substantial value ($100 or less).
Q: Under the Code, may a company compensate a consultant for bona fide services by providing an item with a legitimate patient benefit in lieu of paying an honorarium or fee?
A: If the consulting arrangement otherwise complies with the Code, and the fair market value of the item represents reasonable compensation for the services provided, this may be permissible. However, it would be important to comply with all applicable record keeping and reporting requirements, just as with cash compensation. The written agreement for the consulting services should set forth the compensation and its fair market value, and disclose that this is taxable income.
To read the complete version of the revised PhRMA code as well as the questions and answers, please click on PhRMA Code.
Delaware doctor indicted for Medicare fraud
Published on line 11/07/08
A Seaford, Delaware doctor is being sued by the federal government for alleged Medicare fraud. The suit claims family practice physician Hipolito Aguillon submitted more than 2,400 inflated Medicare reimbursement claims between March 2005 and December 2006. Aguillon is a family practice physician who works out of Seaford. According to Delaware’s U.S. Attorney Colm Connolly, the state’s Medicare carrier has known about Aguillon’s suspect billing since 2002. He is also accused of altering documentation to support the bogus claims. U.S. Attorney for Delaware Colm Connolly says the state's Medicare carrier has known about Aguillon's improper billing practices since 2002. If the government prevails in the civil suit, it could collect between $5,500 and $11,000 for each allegedly false claim.
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Local
News
Local Doctor Guilty of Health Care Fraud
Published on line 02/25/2009
Oklahoma City federal jury found a local doctor guilty of 53 counts of illegally dispensing thousands of tablets of controlled prescription drugs, health care fraud and obstruction of justice, according to John C. Richter, U.S. attorney for the Western District of Oklahoma.
“The rule of law applies to all,” Richter said. “As the verdict shows, this doctor violated his oath to heal in order to be simply a drug dealer of painkillers known for addictiveness and abuse. But he did not stand pat with just those crimes. Instead, he then billed the American taxpayer, through Medicaid, for his illegal drug dealing. And then, when he learned he was being investigated, sought to obstruct our investigation through falsifying patient records subpoenaed by the government.”
The trial last approximately four days. The jury deliberated for about 45 minutes before finding the physician guilty on all 53 counts. A sentencing date will be set by the court in about 90 days, officials said. The doctor faces up to 20 years in prison and a fine of up to $1 million. The jury also found that, after receiving a subpoena for patient records April 7, 2008, as part of the investigation, the doctor falsified patient records with the intent to impede, obstruct and influence the investigation, Richter said.
Richter said the doctor issued prescriptions without conducting physical examinations, taking vital signs or ordering tests, and individuals who were addicted to the drugs knew they could see the doctor and within minutes receive a prescription. “Evidence showed that individuals were lined up outside his office before it opened in order to receive the prescriptions on a first come, first served basis,” Richter said.
The physician submitted fraudulent claims for reimbursement to the Medicaid system, Richter said. Evidence showed the doctor submitted claims on behalf of a patient never seen or treated, and on behalf of individuals for whom he claimed to have performed comprehensive examinations when, in fact, he had spent only minutes with the individual seeking the drugs, Richter said.
To read the complete details of this article, please click here - Local Doctor
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