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Institutional Compliance Agreement Final Mandatory Compliance Training January 2007. Presented By: Andrew S. Quinn, Esq. Principal Compliance Concepts, Inc. www.complianceconcepts.com. Institutional Compliance Agreement (ICA). Agreement between the
Final Mandatory Compliance Training
Andrew S. Quinn, Esq.
Compliance Concepts, Inc.
Office of the Inspector General (OIG) of the DHHS
Annual Training for all Covered Persons:
A Compliance Structure:
In the event of a breach / default the Penalties are:
Material breach of the ICA
may warrant EXCLUSION
from federally funded programs
OIG Proposes To Exclude Miami Hospital from
Participation in Federal Health Care Programs
Inspector General Daniel R. Levinson announced today that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) notified Miami’s South Shore Hospital and Medical Center (South Shore) of an impending exclusion from Medicare, Medicaid, and all other Federal health care programs. Today’s action resulted from South Shore’s material breach of the terms of a corporate integrity agreement (CIA) it negotiated with OIG in 2002, as part of the resolution of a False Claims Act case against the hospital.
OIG Excludes Miami Hospital from
Participation in Federal Health Care Programs
Inspector General Daniel R. Levinson announced today that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) is excluding Miami’s South Beach Community Hospital (South Beach), formerly known as South Shore Hospital and Medical Center, from participation in Medicare, Medicaid, and all other Federal health care programs. Today’s action resulted from South Beach’s material breach of the terms of a corporate integrity agreement (CIA) it negotiated with OIG in 2002, as part of the resolution of a False Claims Act case against the hospital.
“South Beach has committed repeated and flagrant violations of its obligations under the CIA,” said Inspector General Levinson. “This exclusion sends a clear message to the provider community that the OIG will not hesitate to pursue an action against those providers that fail to abide by their integrity agreement obligations.”
Healthcare fraud is the #2 priority of the Department of Justice, second only to terrorism and violent crime.
Healthcare fraud is now, for the first time, a separate federal crime.
FBI Operational Directive
“With health care expenditures rising at three times the rate of inflation, it is especially important to coordinate all investigative efforts to combat fraud within the health care system. The FBI is the primary investigative agency involved in the fight against health care fraud that has jurisdiction over both the federal and private insurance programs. With more than $1 trillion being spent in the private sector on health care and its related services, the FBI's efforts are crucial to the success of the overall program.”
United States Attorney
District of Nevada
DIAGNOSTIC LABORATORY INDICTED FOR FRAUD & ILLEGAL KICKBACKS TO NEVADA PHYSICIANS
- Estimated Loss To Insurance Companies and Medicare Is Over $20 Million –
LAS VEGAS - -A California medical diagnostic testing company which operated clinics in Las Vegas, Nevada, and its two top corporate officers, have been indicted on federal health care fraud, money laundering, and tax evasion charges, announced Daniel G. Bogden, United States Attorney for the District of Nevada.
SDI FUTURE HEALTH, INC. ("SDI"), a California corporation based in Westlake Village, TODD STUART KAPLAN, age 46, of Thousand Oakes, California, and JACK BRUNK, age 48, of Newbury Park, California, were indicted by the Federal Grand Jury in Las Vegas yesterday and charged with one count of Conspiracy to Commit Health Care Fraud; 124 counts of Health Care Fraud; one count of violating the Medicare Anti-Kickback statute; one count of Conspiracy to Commit Money Laundering; and 10 counts of Attempt to Evade or Defeat Tax. They face up to 20 years in prison and fines of $250,000 on each of the Health Care Fraud and Money Laundering offenses, and up to five years in prison and fines of $250,000 on the Anti-Kickback and Tax Evasion counts.
United States Attorney
District of Nevada
It was further part of the scheme to defraud that the SDI defendants induced physicians, including Las Vegas physicians, to accept remuneration or "kickbacks" from SDI in exchange for referring patients to SDI labs. The remuneration took the form of:
(1) assigning SDI employees [referred to as Health Service Coordinators (HSCs)] to work, free of charge, in the offices of physicians;
(2) direct cash payments under the guise of medical director fees;
(3) gifts of expensive sports memorabilia; and
(4) assignment of fees.
SDI allegedly used their HSC's to evaluate patients for sleep studies and to write prescriptions for medically unnecessary tests. The prescriptions were often written by the HSC without any evaluation of the patient's medical condition by a physician and without the presence of any signs and symptoms indicating a medical need for the sleep studies or heart monitoring.
United States Attorney
District of Nevada
SDI defendants also allegedly pressured patients to make appointments at SDI clinics, and informed them that their treating physicians had ordered the sleep studies.
No Las Vegas physicians are specifically charged in the Indictment; however, it is alleged that between January 1999 and January 2002, the SDI defendants entered into agreements with physicians A, B, C, D, and E, who were physicians practicing in Las Vegas, and that the agreements called for payment of kickbacks in return for referrals to SDI.
During the relevant time frame, SDI treated in excess of 15,000 patients. The estimated loss to the victims is approximately $22 million.
The Indictment alleges that if convicted, the defendants shall forfeit approximately $24 million to the United States, because the monies were derived from the proceeds of their offenses.
October 12 , 2005
TWO DOCTORS INDICTED IN 'RENT-A-PATIENT' SCHEME THAT BILLED INSURANCE COMPANIES FOR UNNECESSARY SURGERIES
In the latest legal action targeting "rent-a-patient" scams, two medical doctors have been charged with health care fraud for allegedly performing unnecessary medical procedures on patients who were compensated with money or other benefits.
A federal grand jury in Los Angeles yesterday indicted the two doctors, as well as the Bel Air Surgical Institute, on conspiracy and health care fraud charges for allegedly submitting fraudulent bills to numerous private insurance companies and for allegedly providing false patient records to support those fraudulent bills.
The 17-count indictment outlines a scheme in which Bahna allegedly hired "marketers" who oversaw the recruitment of people who had private health insurance and were willing to undergo unnecessary surgical proceedures in exchange for cash or discounted cosmetic surgery procedures. The procedures performed by the doctors at the Bel Air Surgical Institute included Esophagogastroduodenscopy (EGD), colonoscopy, sinus surgeries, laparoscopy and thoracic sympathectomy, which is commonly called "sweaty palm surgery."
According to the indictment, those willing to undergo the unneeded procedures were promised $300 for EGDs and colonoscopies and up to $1,200 for sweaty palm surgery.
Patients were instructed by recruiters to describe false and exaggerated symptoms which were used to create medical charts used to make the surgical procedures appear to be justified.
Court vindicates Nevada doctor in latest twist of fraud case
A federal judge ruled that a physician was abiding by Medicare's advice in submitting claims for pulmonary stress tests. The government is pursuing an appeal.
By Amy Lynn Sorrel, AMNews staff. Sept. 4, 2006.
Wired witnesses, tapped phones and whistle-blowers. This may sound like plot features in a spy movie, but it's real life for Nevada physician R.D. Prabhu, MD. The federal government has been investigating the internist and pulmonology specialist on and off for more than 13 years.
Dr. Prabhu's story just took a new turn. A federal court in July found that the government's fraud charges didn't hold up because the doctor was just following Medicare instructions.
The Justice Dept. accused Dr. Prabhu of knowingly submitting unlawful bills for simple pulmonary stress tests as part of a pulmonary rehabilitation program. The government alleged that the doctor had violated the False Claims Act because the tests were not covered by Medicare and because he had failed to document their medical necessity for some patients.
But the U.S. District Court for the District of Nevada found that "Dr. Prabhu has always acted in good faith in seeking to understand the government's rules ... in an area rife with confusion."
The decision is a rare victory for doctors, said Robert S. Salcido, a Washington, D.C.-based attorney for Dr. Prabhu. Physicians are often forced to settle such disputes with the government, even when they believe they are acting appropriately, because the financial stakes are so high.
Nevada U.S. attorney given walking papersBy FRANCIS MCCABE REVIEW-JOURNAL Daniel Bogden
The Bush administration has forced Daniel Bogden out of his position as U.S. attorney for the District of Nevada, Nevada's two senators said Sunday.
It was unclear whether Bogden was fired or asked to resign and for what reason. Exactly when it all happened also was unknown Sunday. Repeated attempts to contact Bogden and his office were unsuccessful. The Review-Journal's phone calls to his spokeswoman, Natalie Collins, were not returned by Sunday night.
But a source inside the Nevada U.S. attorney's office said Bogden was seen as indecisive, secretive and insular. Morale in the Southern Nevada office was low and that was partly Bogden's fault and partly the result of inadequate staffing and funding from the Justice Department, the source said.
The Nevada U.S. attorney's office also had at least three major setbacks in Las Vegas last year.
Also in February, U.S. District Judge Robert Jones dismissed charges against Dr. R.D. Prabhu, a politically active Las Vegas pulmonologist. Prosecutors had alleged that Prabhu had submitted false Medicare claims. He had faced a potential penalty of $22 million.
U.S. attorney has had ups and downs while in office
The Department of Justice
Health Care Fraud and Abuse Control Program
Annual Report For FY 2005
Pharmaceutical Distribution Fraud
Pharmaceutical Distribution Fraud
False Claims by a Research University
First: The OIG believes that the great majority of medical professionals are working ethically to render high quality care and to submit proper claims to Medicare.
Second: Under the law, physicians are not subject to civil or criminal penalties for innocent errors, or even negligence. The primary enforcement too, the civil False Claims Act, covers only “actual knowledge, reckless disregard, or deliberate ignorance.
Third: Even the best physicians and their staffs make billing mistake and errors through inadvertence or negligence. When billing errors, honest mistakes, or negligence result in erroneous claims, the physician practice will be asked to return the funds erroneously claimed but without penalties.
Providing medically unnecessary services
Billing for services rendered but not covered
Billing outpatient services for inpatient stays (72-hour rule)
Teaching physician and resident/supervision requirements
Duplicate or erroneous billing
False cost reports
Billing for discharges in lieu of transfer
Contractual Agreements between Hospitals and Physician not grounded in fair market valuationRisk Areas of OIG Concern
These problems can be caused by intentional or unintentional behavior
Recently, GAO made 300 test calls to 34 call centers operated by Medicare Carriers throughout the United States. GAO concluded that only 4% of the responses received were complete and correct.
OIG US Postal State Medicaid Agency
FBI Treasury Competitor
DEA Lawyers Employee
IRS Patient Neighbor
Carrier Ex-Spouse Whistleblower
Referred for Prosecution
Civil Monetary Penalties
U.S. Attorney’s Office
Civil Investigative Demands
File False Claims Act Complaint
Health Care Fraud Task Force
Documentation must support the service code billed, the level of service billed, and the reasonableness and necessity of the service.Complex Medical Review Audits (CMRA)
Specifically targeted or abused CPT codes
Randomly selected providers seeking new UPIN numbers
Providers who seem to be billing incorrect code(s)
Providers who appear to be abusive because they are either not rendering the service they bill for, or they consistently bill for a higher level service than provided.Complex Medical Review Audits (CMRA)
The following are some of the reasons a provider may be reviewed in a postpayment CMR:
Comprehensive Error Rate Testing (CERT)
The CERT program measures the error rate for claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs). The CERT methodology includes:
Randomly selecting a sample of approximately 120,000 submitted claims
Requesting medical records from providers who submitted the claims
Reviewing the claims and medical records for compliance with Medicare coverage, coding and billing rules
CMS provides the following overview of the RAC process:
RACs receive a data file from CMS containing National Claims History (NCH) data about claims that have been processed in the appropriate state based on the RAC contract. The RACs will receive a data file updating the NCH data on a monthly basis.
Assuming that claims have not been suppressed because of an ongoing post payment medical review investigation, an ongoing fraud or benefit integrity investigation or a potential criminal investigation, or inclusion in the CERT sample, the RAC will continue with the identification and recoupment process.
It is a crime to knowingly and willfully execute (or attempt to execute) a scheme to defraud any health care benefit program, or to obtain money or property from a health care benefit program, through a false representation. This law applies not only to federal healthcare programs but to most other types of benefit programs, such as commercial health insurance plans.
Examples of conduct that frequently give rise to liability include the following:
Note: On every HCFA 1500 claim form, a physician must certify that the services rendered were medically necessary for the health of the beneficiary.
Government regulation which restricts physicians from referring their Medicare patients to health organizations in which they have a financial interest
Prohibits a physician from making referrals (or establishing plans of care) for certain “designated health services” when those services were:
Examples of violations of the Stark Law include the following:
The following are examples of conduct that violate the Anti-Kickback Statute:
False Claims Act (FCA) – (31U.S.C.3729-3733)
A false claim is a claim for payment of services that were not provided specifically as presented, or for which the provider is otherwise not entitled to payment.
A person who knowingly submits a false or fraudulent claim to the government, or makes a false statement to get such a claim approved, is liable for both damages and penalties.
31 U.S.C. 3729(a)
Penalty for violation of the FCA:
(FCA amount x 3)
After verdict – Federal judge ordered payment in the amount of $18,415,000 from Dr. Lorenzo.
Taxpayers Against Fraud Education Fund | Washington, D.C. | WWW.TAF.ORGOctober 4, 2006Record Fraud Recoveries Under the False Claims Act20-Year Old Law One of Nation's Most Effective
Fiscal Year 2006 will be a record year for False Claims Act recoveries, says Taxpayers Against Fraud, which estimates total settlements and judgments will top $3.142 billion. This figure does not include more than $200 million in settlements which have been announced by companies but not yet green-lighted by the U.S. Department of Justice.Notes Jim Moorman, President of Taxpayers Against Fraud, "We have seen extraordinary fraud settlements this year. The whistleblowers, investigators, and private and Department of Justice attorneys that have worked on these cases deserve a huge thank you from the American people."
Moorman notes that 80 percent of all successfully resolved FCA cases are brought to the government by whistleblowers, and while the amount of money being recovered is going up, the actual number of cases being settled has not. This is because the U.S. Department of Justice's Civil Division has not been given the resources to handle its False Claims Act case load. "The folks at DOJ are working very hard, but they need more resources from Congress and the Administration."
To date, False Claims Act, judgments and settlements have totaled over $23 billion.
False Claims Act Update & AlertTaxpayers Against Fraud Education Fund | Washington, D.C. | WWW.TAF.ORGFebruary 3, 2006
Congress Creates New Tools to Fight Medicaid FraudWith passage of the Deficit Reduction Omnibus Reconciliation Act of 2005 (S.1932), Congress has forged two new tools to combat Medicaid fraud. Incentives for State FCA's: Section 6031 of the new budget reconciliation bill would increase state awards from False Claims Act litigation by 10 percentage points if the state has adopted a state False Claims Act law as strong as the federal version. For example, if a state's federal matching rate is 57 percent, it would typically receive only 43 percent of the amount recovered from the fraudfeasor. However, if the State has enacted a qualifying False Claims Act, its share of any recovery would increase by 10 percentage points, to 53 percent of any amount received under its False Claims Act. (In this example, the states share of the recovery effectively increases by 23 percent!) Required False Claims Act Education: Section 6032 of the new budget reconciliation bill requires any entity that receives or makes annual Medicaid payments of $5 million or more to include in their employee handbook a detailed discussion of the provisions of the federal and states False Claims Acts, including the rights of whistleblowers.
“Presence and Participation”
Apply to the Following Services:
Health Care Offenses (18 U.S.C. 1518)
Knowingly and willfully prevent or attempt to mislead or delay communication of records relating to a Federal health care offense to a criminal investigator.
Criminal Charges (cont):
“Dr. Winn obstructed the investigation by a) instructing witnesses in the investigation to omit statements that would incriminate him; b) deliberately providing false exculpatory information to witnesses with the intent that they would provide that false information to those conducting the investigation; c) persuading witnesses to make material misrepresentations of facts to those conducting the investigation so that they would not provide information that incriminated him; and further d) by creating an atmosphere of fear and intimidation within the Department of Neurological Surgery.”
Excerpt from Press Release of the United States Attorney's Office
Payors (including MEDICARE) require reasonable documentation to ensure that services provided are consistent with coverage. Information is often requested to validate the following:
The Department of Health and Human Services Office of Inspector General (OIG) has published its 2007 Work Plan. The Work Plan outlines the OIG’s priorities for the fiscal year, including areas likely to be targeted for audits.
Following are some of the areas included in the Work Plan that affect physicians:
OIG will examine physician coding of E&M services for aberrant coding patterns, high volume of high level codes resulting in greater Medicare reimbursement.
OIG will examine the appropriateness of billing these services and the reasons for inappropriately billed services.
(Consults require all three elements including History, Exam, Medical decision making to qualify as a consult)
OIG will examine whether place of service was properly coded on submitted claims. There are different levels of payment depending on where services are performed. Higher payment is made for place of service “11”, a physicians office.
All billable services require a face to face encounter with the patient. OIG will examine the distance between the Doctor providing services and the patients home location. (Example: Doctor is in New York and patient lives in Florida).
Specifically nerve conduction studies due to a 37% increase in allowed amounts for these tests.
OIG will examine these services because incident to services are paid at 100% of the Physician fee schedule and must be provided by an employee of the Physician under the Physicians direct supervision.
Direct supervision is defined as the physician must be present within the office suite, and immediately available throughout the service.
OIG will examine Medicaid claims against the CCI edits to identify Medicaid savings and duplicate physician services.
OIG will review the relationships between billing companies and physicians as well as other Medicare providers to identify the types of arrangements in place and their impact on physician billing.
To determine if services billed to Medicare as consultations were coded correctly and documented adequately.
Medicare allowed $3.3 billion for consultations in 2001. The Current Procedural Terminology (CPT) defines a consultation as “ . . . a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” A consultation differs from similar evaluation and management services in that a consultation involves a specific request for help with a particular diagnosis or course of treatment on a limited basis, while an office or inpatient visit lacks such a request and can involve ongoing care of a patient.
Medicare allowed approximately $1.1 billion more in 2001 than it should have for services that were billed as consultations.
Approximately 75 percent of services billed as consultations and allowed by Medicare in 2001 did not meet all applicable program requirements, resulting in $1.1 billion in improper payments. Services billed as consultations often did not meet Medicare’s definition of a consultation (19 percent - $191 million), were billed as the wrong type or level of consultation (47 percent - $613 million), or were not substantiated by documentation (9 percent - $260 million). Consultations billed at the highest billing level (the most complex services, which generate the highest reimbursements under the physician fee schedule) and follow-up inpatient consultations were particularly problematic; approximately 95 percent of each were miscoded.
Our review showed that services billed to Medicare as consultations often were not actually consultations, were coded as the incorrect type or level of consultation, or were not substantiated by documentation. Although CMS clarified the difference between office visits and consultations in an October 2003 update to section 15506 of the Medicare Carriers Manual, the distinctions among the types and levels of consultations were not addressed. Therefore, we recommend that, through its Medicare carriers, CMS educate physicians and other health care practitioners about the criteria and proper billing for all types and levels of consultations with emphasis on the highest billing levels and follow-up inpatient consultations.
In addition, we have forwarded information on the miscoded and undocumented services identified in our sample to CMS for appropriate actions.
“if it is not documented, it wasn’t done.”
Report Conduct that Concerns You
– and may we never meet again.