DOJ is Criminally Prosecuting Virginia Physician Who Improperly Disclosed Patient Health Information
(June 24, 2011): Physicians and other health care providers should take care — improprerly disclosing a patient’s protected individual health information could land you in Federal prison. Earlier this week, Virginia osteopath was indicted in the Eastern District of Virginia on charges that he illegally disclosed a former patient’s health information to the patient’s employer. The Virginia physician was indicted by a Federal Grand Jury for the wrongful disclosure of individually identifiable health information under the Health Insurance Portability and Accountability Act (HIPAA). The physician reportedly faces a maximum of up to five years imprisonment if convicted. According to the indictment, the physician practiced osteopathic ...
CMHC Compliance Officers Should Review Their Compliance Plans to Ensure that “I-9s” are Being Properly Handled and Completed by Staff. The Failure to do so Can Result in Civil and / or Criminal Penalties.
(November 28, 2010): In 2003, the Immigration and Naturalization Service (INS) was became part of the U.S. Department of Homeland Security. Despite this change, certain functions, such as responsibility for enforcing citizenship discrimination actions remained with the U.S. Department of Justice's Office of Special Counsel for Immigration-Related Unfair Employment Practices (DOJ-OSC). As one large not-for–profit hospital group recently found, DOJ-OSC takes this responsibility quite seriously and is aggressively investigating allegations of “citizenship status discrimination” committed by employers (including health care providers). Most recently, DOJ-OSC has pursued violations allegedly occurring when prospective applicants were asked to show that they are eligible ...
The Zone 7 ZPIC Has Recommended Revocation of 82% of CORFS and 79% of CMHCs in South Florida – Is Your ZPIC Next?
(October 9, 2010): In late 2008, SafeGuard Services LLC (SafeGuard) was awarded one of the first two contracts to serve as a Zone Program Integrity Contractor (ZPIC) for Zone 7, an area which includes Florida, Puerto Rico and the U.S. Virgin Islands. The contract covered a base year plus four additional years. SafeGuard’s appointment was one of the first actions taken to consolidate the work previously performed by Program SafeGuard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs). Among its consolidated duties, SafeGuard is responsible for handling medical reviews and benefit integrity functions for Medicare claims under both Part A ...
Is the Government Overreaching with its use of the False Claims Act? The AHA Sure Seems to Think So.
(September 11, 2010): Earlier this week, the American Hospital Association (AHA), a primary industry association for hospitals around the country, wrote to DOJ Attorney General Eric Holder and HHS Secretary Kathleen Sebelius, to express the hospitals’ concern that the government may be overreaching in its use of the False Claims Act (FCA). As you will recall, the FCA is the primary civil enforcement tool used by DOJ in pursuing civil health care fraud violations. The FCA’s reach is long (under certain circumstances it can cover claims up to ten years old) and its impact can be devastating on providers. Violations ...
Additional Cities will have HEAT Teams in 2011
(August 27, 2010): Yesterday, Attorney General Eric Holder and U. S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius conducted the second of a planned series of “Regional Health Care Fraud Prevention Summits.” The first summit was recently conducted in Miami, Florida. This summit was held in Los Angeles, California. In addition to these agency heads, summit participants learned of current and additional planned initiatives from a number of Federal and State law enforcement officials. Describing the progress made in the last fiscal year, Attorney General Holder noted that: "In just the last fiscal year, we’ve won or negotiated more than $1.6 ...
“Medical Records Retention” Issues Continue to be Important for CMHCs
(August 17, 2010): The Centers for Medicare and Medicaid Services (CMS) recently issued MLM Matters SE1022, titled “Medical Record Retention and Media Formats for Medical Records” which serves as a helpful reminder regarding a number of medical records retention issues faced by Community Mental Health Centers (CMHCs) around the country. As reflected in the guidance, MLM Matters SE1022 directly applies to health care providers (such as CMHCs) submitting claims to Medicare contractors for services provided to Medicare beneficiaries. While medical record retention requirements are generally governed by State law and can vary from State to State, it is important to remember that under HIPAA's administrative simplification rules, “covered entities” ...
CMS is Requiring that ZPICs and PSCs Strictly Adhere to “Signature Requirements” When the Contractors are Conducting Medical Reviews
(August 4, 2010): The Centers for Medicare and Medicaid Services (CMS) has recently updated its "signature requirement" instructions to Medicare contractors, Change Request (CR) 6698, (including affiliated contractors such as CERT reviewers, ZPICs and PSCs) to be applied as they conduct Medicare claims audits and reviews. As the guidance reflects, this issuance is intended to “clarify and update” Medicare's Program Integrity Manual. Importantly, this guidance is not intended to replace any existing specific requirements that may be contained in LCDs or other CMS manuals which may set out specific signature requirements (such as signature and timeliness requirements which must be made in connection with Treatment ...
With ZPICs, PSCs, and RACs Fighting Most, If Not All, Extrapolation Challenges, Experienced Counsel Is Imperative if You Hope to Have the Extrapolation Invalidated
(July 20, 2010): In recent years, we have seen agents for the Centers for Medicare & Medicaid Services (CMS) increasingly rely on statistical extrapolation estimates when assessing claims overpayments. In early cases, we successfully invalidated countless extrapolations by identifying relatively basic reasons for why the calculations were inconsistent with accepted statistical principles and practices. Now, however, providers should expect for ZPICs and PSCs (and soon, RACs) to send a team of statisticians and attorneys to vigorously oppose most (if not all) hearings challenging the validity of the extrapolation calculation. Regardless of whether you are providing Partial Hospitalization, Evaluation and Management (E/M), ...
Medicare Fraud Strike Force Operation Leads to Charges against 94 Defendants, including 4 in South Texas
(July 17, 2010): Yesterday, the Department of Justice (DOJ) announced charges against 94 physicians, medical assistants, and health care company owners and executives in connection with alleged false Medicare claims amounting to more than $251 million. 24 defendants from Miami account for approximately $103 million of that amount. Four defendants were charged in Houston for their alleged roles in a $3 million scheme to submit fraudulent claims for durable medical equipment (DME). Other arrests were made in Baton Rouge, Brooklyn, and Detroit. The offenses charged include conspiracy to defraud the Medicare program, criminal false claims, violations of the anti-kickback statutes, and ...
“Finders Keepers” Doesn’t Apply to Medicare Overpayments for Partial Hospitalization Services
(July 15, 2010): Since the May 2009 passage of the Fraud Enforcement and Recovery Act (FERA) and subsequent enactment of the PPACA, we’ve heard a lot about how the government looks at Medicare overpayments for partial hospitalization services and how Community Mental Health Clinics (CMHCs) should handle them. Two major misconceptions seem to underlie the public response to provisions clarifying that failure to timely refund Medicare overpayments can result in False Claims Act (FCA) liability. I. Historical Overview of the “Overpayment” Issue Prior to the clarification and statutory reinforcement of the “overpayment” issue provided by PPACA, a number of CMHCs ...
False Claims Act
Is the Government Overreaching with its use of the False Claims Act? The AHA Sure Seems to Think So.(September 11, 2010): Earlier this week, the American Hospital Association (AHA),...
“Finders Keepers” Doesn’t Apply to Medicare Overpayments for Partial Hospitalization Services(July 15, 2010): Since the May 2009 passage of the Fraud Enforcement and Recovery...
PPACA Creates a Minefield for CMHCs Who Fail to Promptly Return an Overpayment(July 9, 2010): Does the failure of a CMHC to promptly return a Medicare overpayment warrant...
The “Fraud and Abuse” Enforcement Impact of the Health Care Reform Bill on Community Mental Health Clinics and the Partial Hospitalization Program Services They Provide(April 1, 2010): On March 21, 2010, the House voted to approve legislation previously...
Read More Posts From This CategoryMedicare Audits
DOJ is Criminally Prosecuting Virginia Physician Who Improperly Disclosed Patient Health Information(June 24, 2011): Physicians and other health care providers should take care —...
CMHC Compliance Officers Should Review Their Compliance Plans to Ensure that “I-9s” are Being Properly Handled and Completed by Staff. The Failure to do so Can Result in Civil and / or Criminal Penalties.(November 28, 2010): In 2003, the Immigration and Naturalization Service (INS) was...
The Zone 7 ZPIC Has Recommended Revocation of 82% of CORFS and 79% of CMHCs in South Florida – Is Your ZPIC Next?(October 9, 2010): In late 2008, SafeGuard Services LLC (SafeGuard) was awarded...
HHS-OIG has Identified “Partial Hospitalization Program Services” as a New Audit Area of Interest in its 2011 Work Plan(October 1, 2010): This afternoon, HHS-OIG issued its 2011 Work Plan setting out...
Read More Posts From This CategoryHEAT Enforcement
Additional Cities will have HEAT Teams in 2011(August 27, 2010): Yesterday, Attorney General Eric Holder and U. S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius conducted the second of a planned series of “Regional Health Care Fraud Prevention Summits.” The first summit was recently conducted in Miami, Florida. This summit was held in Los Angeles, California. In... [Read more of this review]
Medicare Fraud Strike Force Operation Leads to Charges against 94 Defendants, including 4 in South Texas(July 17, 2010): Yesterday, the Department of Justice (DOJ) announced charges against 94 physicians, medical assistants, and health care company owners and executives in connection with alleged false Medicare claims amounting to more than $251 million. 24 defendants from Miami account for approximately $103 million of that amount. Four defendants... [Read more of this review]
Texas Psychiatrist Indicted and Arrested(July 9, 2010): On June 14, 2010 the U.S. Attorney’s Office for the Western District of Texas announced that a Federal Grand Jury had returned a 99-count indictment against a pain management physician who operated clinics in San Antonio and El Paso. The physician was charged with 21 counts of health care fraud, 20 counts of false statements relating... [Read more of this review]
Owner of Texas Behavioral Health Counseling Clinic Pleads Guilty to Medicare Fraud(June 5, 2010): Early last week, the U.S. Attorney’s Office in Houston, Texas announced that a plea agreement had been reached with the owner of a behavioral counseling center in Houston. The owner pled guilty to (1) conspiracy to commit health care fraud, (2) health care fraud and (3) aggravated identity theft, all arising out of the defendant’s... [Read more of this review]
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