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You are here : Resources  >  View
Vol. XVI, No. 15
4/11/2014 12:00:00 AM

This Week’s Headlines – April 11, 2014

Medicare data will help public fight fraud, officials say
HHS Secretary Kathleen Sebelius resigns
Morris County (NJ) physician admits taking bribes in test referrals scheme with New Jersey clinical lab
Former University Of Louisville executive charged with embezzling funds tied to UofL medical groups and tax fraud
Indictment: Kansas home health worker's bills claimed she was working up to 39 hours a day
Detroit home health agency office manager sentenced for her role in $5.8 million Medicare fraud scheme
OIG reverses opinion on referral discounts, online info exchange service
Physical therapy clinics to pay $2.78 million to resolve False Claims Act allegations
Toms River (NJ) chiropractor pleads guilty to taking kickbacks for patient referrals
Woman accused of posing as physician’s assistant

This Week’s Links

Regulatory News

Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid

CMS Update

In the Federal Register

CMS Transmittals

From the OIG

Acronym Library


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Headlines

Medicare data will help public fight fraud, officials say
On April 10, 2014, USA Today reported, “The government released Medicare payment data for 880,000 providers Wednesday in part so that the public — and journalists — could double-check the information for fraud, officials said Wednesday.

“‘We know that there's waste in the system, we know that there's fraud in the system,’ said Jonathan Blum, principal deputy administrator for the Centers for Medicare and Medicaid Services. ‘We want the public's help — we want reporters' help — with data that appear to be fraudulent.’

“For the past 35 years, the data have been kept from the public because the American Medical Association feared that people would not understand the data. Privacy was another concern.” For more

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HHS Secretary Kathleen Sebelius resigns
On April 10, 2014, USA Today reported, “After a difficult five years shepherding President Obama's signature health care law, Health and Human Services Secretary Kathleen Sebelius has tendered her resignation, according to two senior administration officials.

“Obama accepted the resignation this week and intends to announce that he will nominate Office of Management and Budget Director Sylvia Mathews Burwell to replace Sebelius.

“He will make the formal announcement at 11 a.m. Friday at the White House, according to officials, who asked not to be identified so as not to pre-empt the president.” For more

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Morris County (NJ) physician admits taking bribes in test referrals scheme with New Jersey clinical lab
On April 9, 2014, U.S. Attorney for the District of New Jersey Paul J. Fishman announced in a press release, “A physician with a practice in Madison, New Jersey admitted today to accepting bribes of $2,000 per month in exchange for test referrals as part of a long-running scheme operated by Biodiagnostic Laboratory Services LLC (BLS) of Parsippany, New Jersey; its president; and numerous associates.

“Wayne Lajewski, 51, pleaded guilty today before U.S. District Judge Stanley R. Chesler in Newark federal court to an information charging him with one count of accepting bribes.” For more

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Former University Of Louisville executive charged with embezzling funds tied to UofL medical groups and tax fraud
On April 2, 2014, U.S. Attorney for the Western District of Kentucky David J. Hale announced, “A former University of Louisville accountant, promoted to Executive Director of the Department of Family & Geriatric Medicine at the University of Louisville School of Medicine (DFGM) was arraigned today on a seven-count federal indictment charging theft and bribery in programs that receive federal funds, money laundering, mail fraud, and filing false federal income tax returns.

“As part of the nearly six year scheme, Perry Chadwick Vaughn, 36, of Sellersburg, Indiana, allegedly diverted contractual checks and patient payments to the University Family and Geriatric Medicine Associates account then withdrew $2,809,489 for his personal use and benefit.” For more

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Indictment: Kansas home health worker's bills claimed she was working up to 39 hours a day
On April 9, 2014, U.S. Attorney for the District of Kansas Barry Grissom and Kansas Attorney General Derek Schmidt announced, “A Kansas City, Kan., woman working as a personal care attendant was indicted Wednesday on a federal charge that Medicaid paid more than $587,000 based on fraudulent bills she submitted. 

“Doris Betts, 54, Kansas City, Kan., was charged with six counts of health care fraud. The indictment alleged the crimes occurred while Betts was claiming to provide personal services, residential support, day support, and sleep cycle support for seven different Medicaid consumers through four different billing agencies since January 2008. Personal services include bathing, house cleaning, meal preparation, toileting, transferring and prompting patients to take medication.” For more

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Detroit home health agency office manager sentenced for her role in $5.8 million Medicare fraud scheme
On April 8, 2014, Acting Assistant Attorney General David A. O’Neil of the Justice Department’s Criminal Division announced, “The office manager of a Detroit-area home health agency was sentenced today to serve 46 months in prison for her role in a $5.8 million Medicare fraud scheme.”

According to the government press release, “Nabila Mahbub, 28, was sentenced by U.S. District Judge Denise Page Hood in the Eastern District of Michigan.  In addition to her prison term, Mahbub was sentenced to serve two years of supervised release and was ordered to pay more than $3 million in restitution, jointly and severally with her co-defendants.

“A jury convicted Mahbub of one count of health care fraud conspiracy in April 2013. According to evidence presented at trial, the defendant and her co-conspirators caused the submission of false and fraudulent claims to Medicare through All American Home Care Inc., a home health   care company located in Oak Park, Mich., that purported to provide skilled nursing and physical therapy services to Medicare beneficiaries in the greater Detroit area.” For more

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OIG reverses opinion on referral discounts, online info exchange service
On April 9, 2014, Health Data Management reported, “The Department of Health and Human Services' Office of Inspector General has terminated its own 2011 advisory opinion regarding financial incentives for referrals from health professionals to an online service that facilitates the exchange of information between healthcare providers and suppliers.”

According to the report, “Gregory Demske, OIG's chief counsel, in a redacted letter states that the office now concludes that ‘the financial incentive provided to ordering health professionals under the arrangement could induce the ordering health professionals to select trading partners rather than non-trading partners, particularly with respect to services the ordering health professionals order with a high degree of frequency, such as laboratory tests.’

“In the letter, Demske writes that OIG ‘continues to believe that the efficient exchange of health information between health professionals is a laudable goal.’ Nevertheless, ‘when evaluating an advisory opinion request regarding an exchange that involves referrals of federal healthcare program business, the OIG also must consider whether the means used to achieve that goal present more than a minimal risk of fraud and abuse under the anti-kickback statute,’ he states.” 
For more | OIG Termination of Opinion 11-08

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Physical therapy clinics to pay $2.78 million to resolve False Claims Act allegations
On April 9, 2014, the U.S. Attorney for the District of Columbia Ronald C. Machen Jr. announced, “Two companies that operate physical therapy clinics in Washington, D.C., Virginia, and Maryland, along with three individuals associated with the businesses, have agreed to pay the United States $2.78 million to settle allegations that the firms’ billings to Medicare and the TRICARE health care program violated the False Claims Act.” 

According to the government press release, “The companies -- Alliance Rehabilitation, LLC and Active Physical Therapy Services, LLC -- submitted invoices to Medicare and TRICARE through a consolidated billing office in Fairfax, Va., that was managed and overseen by Geeta Trehan, of Virginia.  The companies’ owners, Thomas Bray and Rajeev Gupta, both of Maryland, also managed the operations.” For more

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Toms River (NJ) chiropractor pleads guilty to taking kickbacks for patient referrals
On April 10, 2014, Asbury Park Press reported, “Norman Eastburn, a Toms River chiropractor, admitted Wednesday to accepting bribes in exchange for referring a number of his patients to a state-licensed pain-management physician, announced U.S. Attorney Paul J. Fishman.

“Eastburn, 48, who lives in Jackson but whose practice is in Toms River, pleaded guilty to one count of violating the anti-kickback statute. He entered his guilty plea before U.S. District Judge Stanley R. Chesler in federal court in Newark, according to a prepared statement from the U.S. Attorney’s Office.

“Eastburn was paid a cash fee for each patient he sent to the pain specialist. As part of the scheme, the pair negotiated specific kickback amounts that would be paid based on what each patient was billed —either through Medicare or a private healthcare insurer —and what type of pain treatment would be rendered.” For more | DOJ Press Release

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Woman accused of posing as physician’s assistant
On April 4, 2014, the Washington Post reported, “Maryland’s U.S. Attorney’s Office says a woman has been indicted of charges of posing as a licensed physician’s assistant, treating Medicaid patients and writing prescriptions.

Prosecutors say 36-year-old Shawna Michelle Gunter of Severna Park was indicted March 18 on charges of wire fraud, aggravated identity theft and health care fraud. The indictment was unsealed when she was arrested on Friday.” DOJ Press Release

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This Week’s Links

OIG Advisory Opinion 14-03 For more

DOJ:
-Justice Department, Federal Trade Commission Issue Antitrust Policy Statement on Sharing Cybersecurity Information.
For more

-Remarks as Prepared for Delivery by Deputy Attorney General James M. Cole at the Pen and Pad Briefing on the Justice Department and Federal Trade Commission Joint Antitrust Policy Statement on Sharing of Cybersecurity Information. For more

- Assistant Attorney General Bill Baer Speaks at the Pen and Pad Briefing on the Justice Department and Federal Trade Commission Joint Antitrust Policy Statement on Sharing of Cybersecurity Information. For more

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This week, MediRegs provided TWCC readers with the following: In the Federal Register, CMS Transmittals, and From the OIG.

Regulatory News

Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid
On April 9, 2014, the U.S. Department of Health and Human Services announced “the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.

“‘Currently, consumers have limited information about how physicians and other health care professionals practice medicine,’ said Secretary Sebelius “This data will help fill that gap by offering insight into the Medicare portion of a physician’s practice. The data released today afford researchers, policymakers and the public a new window into health care spending and physician practice patterns.’

“The new data set has information for over 880,000 distinct health care providers who collectively received $77 billion in Medicare payments in 2012, under the Medicare Part B Fee-For-Service program. With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.” For more

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CMS Update

Dates & Times of Upcoming National Provider Calls
Registration Opening Soon for the following CMS Calls:
- Thursday, April 17; 2:30-4pm ET - Standardized Readmission Ratio for Dialysis Facilities: National Dry Run
- Tuesday, April 22; 1:30-3pm ET - Medicare Shared Savings Program ACO Application Process
- Tuesday, May 20; 1:30-3:00pm ET - National Partnership to Improve Dementia Care in Nursing Homes

To register- To receive call-in information, you must register for calls on the CMS Upcoming National Provider Calls registration website. Space may be limited, register early. Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.

The presentation for calls will be posted on the FFS National Provider Calls web page. A link to the slide presentation will be emailed to all registrants on the day of the call.

Visit the Continuing Education Credit Notification web page for continuing education information

Medicare coverage includes screening and counseling for alcohol misuse
April is Alcohol Awareness Month. This national health observance serves to increase public awareness and understanding, reduce stigma, and encourage local communities to focus on alcoholism and alcohol-related issues.

Alcohol addiction and excessive alcohol misuse affects people of all ages, gender and ethnicities. Seniors and others covered by Medicare can be screened for alcohol misuse under the Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse benefit. Read more .

Probe and Educate Clarifications: Timeframes for Additional Documentation Requests and Education
Under the final rule
CMS-1599-F or “2-Midnight” rule, Medicare Administrative Contractors (MACs) have been performing prepayment patient status probe reviews on a sample of 10 claims for most hospitals (25 claims for large hospitals) with dates of admission on or after October 1, 2013. These “probe and educate” reviews are being conducted to assess provider understanding and compliance with CMS policy on inpatient hospital and critical access hospital (CAH) admissions. Based on the results of the initial reviews, the MACs will conduct individualized educational efforts and repeat the process where necessary. MACs are beginning the education portion of the process and have been instructed to allow providers 45 days before requesting additional documentation. This 45 day timeframe will give hospitals additional time to implement strategies aimed at increased compliance with the rule. CMS has instructed the MACs that any providers with incomplete probe and educate samples (i.e. less than 10 or 25 claims selected and/or received for review) will automatically be offered education and undergo a second probe review, regardless of the results of the first probe review.

CMS Releases Modifications to HCPCS Code Set
The scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set are posted on the
HCPCS Quarterly Update web page. Changes are effective on the dates indicated on the update.

New from MLN
SNFs and Changes in Part B Payment Methodology for Certain DME
MLN Matters® Article MM8566

 “Updating Beneficiary Information with the Benefits Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor)” MLN Matters® Article — Released

 “Mental Health Services” Booklet — Revised

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In the Federal Register

HHS

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CMS Transmittals

2014 Transmittals and MLN Matters:
http://twcc.mediregs.com/cgi-bin/_trial/efgn?c=mre_cms_transmittals&u=2014&h=top1.html&t=80&s=twcc

One-Time Special Notification (PUB. 100-20)

CMS Program Manuals - Provider Reimbursement (PUB. 15)    

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From the OIG
Podcasts, Spotlight Articles, Videos and Related Materials

Audit Reports

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Acronym Library

IOC

Inspection of Care

IP/SNF

Inpatient SNF

IPRP

Interim Payment Review Program  

IPS 

Institutional Provider of Service

Click here for more from CMS Acronyms

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