Ambulatory Services Management Group DOJ Case studies

1. Ambulatory Services Management GroupDOJ Case studies Glena Jarboe Ambulatory Compliance Manager Office of corporate Compliance 859-323-3217 Comply-Line 1-877-898-6072 May 15, 2014

2. Department of Justice The DOJ’s Medicare Fraud Strike Force has set record numbers for health care prosecutions in FY 2013. The Federal government won or negotiated over 2.6 billion in healthcare fraud judgments and settlements. One of the country’s most productive investments—returning approximately $8.00 for each $1.00 spent Since its inception in 2007, strike force prosecutors have charged more than 1,700 defendants who have collectively billed the Medicare program more than $5.5 billion

3. Repayment of 16.5 million • Hospital has agreed to repay $16.5 million to resolve false claim allegations for a variety of medically unnecessary cardiac procedure. Also resolves allegations of Stark and Anti-Kickback statue for financially benefitting the clinic the physicians were associated with for referrals.

4. Federal Court Denies Request for Dismissal Optometrist billed for 100 eye exams in one 8 hour day. By his own billing guideline each visit should have taken 15 minutes. Federal court for the state of Kentucky has denied request for dismissal and litigation is moving forward.

5. Out of state during billed services Physician dispensed prescription drugs to a large percentage of his patients. Since some states limit controlled substance to a 30 day supply, his patients often had regular appointments with him roughly every 30 days to renew their prescriptions, however on some occasions the appointments conflicted with his international travel. He directed his nurse to see the patients, issue a pre-signed prescription and bill Medicare for face to face visit—He faces 5 years in prison and $250K for each offense.

6. Re-imported Drugs Orthopedic Clinic to pay $1.85 million to settle allegation of billing Medicare for reimported products. The government contends that the clinics knowingly purchased deeply discounted drugs that were imported from foreign countries. Medicare does not reimburse re-imported drugs, so the clinic falsely billed them as domestic. The claim settled by these agreements are allegations only; there have been no determination of liability—yet.

7. Kickbacks Pharmaceutical manufacturer pays $40.1 million to settle allegations that it violated the False Claims Act by paying kickbacks and promoting its products for uses that were not FDA approved. The settlement resolves allegations that $11.6 million were paid in kickbacks to one physician while he served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses and recommends standardized health care performance measures and practices. The purpose of those payments was to induce the physician to recommend, promote and arrange for the purchase by HealthCare providers.

8. Tri-State License Physician held license in three (3) states. He opened clinic in all three and paid “transporters” a fee to bring primarily elderly and limited English speaking patients to the clinic in which they were paid $100. Records were generated and Medicare was billed for comprehensive exams and diagnostic testing that were never performed. The clinic billed more than 5 million in charges. Physician and staff are currently serving time varying from 27 months to 10 years.

9. Misappropriated license of physicians Clinic owner pleaded guilty to his involvement in HC fraud of at least $3.4 million for sham mental and behavioral health services. According to court documents he misappropriated the Medicaid provider number of at least 3 licensed clinicians who performed some work for the clinic. He then used their number to bill for services that were either never performed or performed by unlicensed individuals that amounted to mentoring visits that are not reimbursed by Medicaid.

10. Miscellaneous Clinic to re-pay $400k for vein injection services performed by unlicensed staff. 2 sentenced to over 12 years collectively, for fraudulent billing totaling more than 1.2 million for ambulance transport—patient rode in front seat or in captain chairs—but reported via stretcher. National Rehab facility to pay 30 million related to referral of nursing home business. Doctor convicted of taking kickbacks for referral of diagnostic testing. Received a monthly check based on the number and types of referrals—awaiting sentencing. Faces $250k and 5 years in jail.

11. Miscellaneous Dentist sentenced to 18 months and to pay 120k—altered records to include services not performed Pharmacist and 13 employees indicted for returning to stock and re-dispensing drugs that were previously dispensed to nursing homes and adult foster care homes—punishable by up to 10 years and fine of $250k or twice the gross gain of the offense 7 oncologist to pay approximately 2.6 million for importing cancer medications that had not been approved by the FDA.

12. Guess who reported many of these offenses? Staff

13. Questions?