Oxygen equipment provider Lincare pays $5.25M to settle Medicare Advantage fraud suit

https://www.fiercehealthcare.com/payer/lincare-oxygen-durable-equipment-medicare-advantage-fraud-settlement?mkt_tok=eyJpIjoiTjJRMlpERTBObU0yWldOaiIsInQiOiJPMDVjRGNQVzcxMjIzOGt1ZTZva0R2YU1PXC9mYkczVEtYVHNHWmZzSHc1TjU1RGRZZ1o4VVprZStEV3R3VWdXWFwvQlRoYVg4cGpzakZIOFFkMkthRnVPbVwvNEUwQ3ptOVozRGQ0U3IyVDFENENmZTErMjc3TDhRYlwvaUlrT1oxSWgifQ%3D%3D&mrkid=959610

The word fraud framed by other words

One of the country’s largest suppliers of oxygen and respiratory equipment has agreed to pay $5.25 million to settle allegations that it violated anti-kickback laws by reducing copayments for certain Medicare Advantage members.

Lincare has also entered into a corporate integrity agreement with the Office of Inspector General, the Department of Justice announced last week.

The settlement resolves allegations filed by former billing supervisor Brian Thomas, who worked for nearly a decade at the Florida-based company. In his 2015 complaint, which was later joined by federal prosecutors, Thomas claimed Lincare waived copays for Humana’s Medicare Advantage members beginning in December 2011 after the insurer contracted with Apria Healthcare to be an exclusive in-network provider of medical equipment.

In his complaint, Thomas said Lincare matched network benefits by reducing copays from Humana beneficiaries from 30% to 13% to align with copays from Apria. Humana was left paying for a higher charge using government funds.

Lincare was purchased by The Linde Group, a German industrial gas company, for $3.8 billion in 2012. The government alleged Lincare continued the scheme through 2017.

It’s the second major settlement for Lincare, which operates about 1,000 locations across the country. In May, the company paid $875,000 to settle a class action lawsuit from employers who had their information stolen during a data breach.

 

 

 

Vulnerable Rural Hospitals Face Quandaries Over Questionable Billing Schemes

Vulnerable Rural Hospitals Face Quandaries Over Questionable Billing Schemes

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Two rural Missouri hospitals recently handed over their operations to a private company that promised to turn them around with a billing practice it calls “a lab outreach program.”

But the approach that company is using is drawing attention from lawmakers and Missouri’s auditor. It is similar to a tactic underway at 20 rural hospitals in Missouri, Kansas, Oklahoma, Florida and California.

Read KHN’s previous coverage of this topic: “Outsiders Swoop In Vowing To Rescue Rural Hospitals Short On Hope — And Money” by California Healthline senior correspondent Barbara Feder Ostrov.

 

Healogics to Pay Up to $22.5M in False Claims Settlement

https://www.healthleadersmedia.com/finance/healogics-pay-225m-false-claims-settlement

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Whistleblower lawsuits had alleged that the Florida-based wound care specialist knowingly filed bogus claims to Medicare for services that weren’t needed.

Healogics, Inc. will pay up to $22.51 million to settle whistleblower allegations that billed Medicare for medically unnecessary and unreasonable hyperbaric oxygen therapy, the Department of Justice said.

Jacksonville, FL-based Healogics manages nearly 700 hospital-based wound care centers across the nation.

The settlement resolves allegations that from 2010 through 2015, Healogics knowingly submitted false claims to Medicare for medically unnecessary or unreasonable HBO therapy, DOJ said.

Healogics will pay $17.5 million, plus an additional $5 million if certain financial contingencies occur within the next five years, for a total potential payment of up to $22.51 million. The company has also has entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General.

“When greed is the primary factor in performing medically unnecessary health care procedures on Medicare beneficiaries, both patient well-being and taxpayer funds are compromised,” said HHS OIG Special Agent in Charge Shimon R. Richmond.

The settlement came as the result of whistleblower lawsuits filed by a former executive at Healogics, and a separate suit filed by two doctors and a former program director who worked at Healogics-affiliated wound care centers. The four whistleblowers are expected to share $4.2 million of the settlement.

 

 

Banner Health settles whistleblower case for $18 million

https://www.azcentral.com/story/money/business/health/2018/04/12/banner-health-settles-whistleblower-case-18-million/511848002/

Image result for Banner Health settles whistleblower case for $18 million

 

Banner Health has agreed to pay more than $18 million to settle whistleblower claims that the Phoenix-based health system admitted patients who could have been treated less expensively at outpatient facilities.

The settlement resolves a whistleblower case brought by a former Banner Health employee who claimed one dozen hospitals in Arizona and Colorado overcharged Medicare for brief, inpatient procedures that should have been billed on a less costly outpatient basis, the U.S. Attorney’s Office in Arizona said.

The settlement resolves allegations that Arizona’s largest health provider “inflated in reports to Medicare the number of hours for which patients received outpatient observation care during this time period,” according to a statement from the federal prosecutors.

The settlement involved Medicare billing at one dozen hospitals from November 2007 through December 2016.

The case was brought by former Banner Health employee Cecilia Guardiola under the federal False Claims Act, which allows individuals to bring lawsuits on behalf of the government and collect a portion of any settlement. Under terms of the settlement, Guardiola will be paid $3.3 million.

Banner Health said in a statement that the settlement does not include any findings of wrongdoing and allows the system to avoid the costs and disruption of ongoing litigation.

“Banner Health is fully committed to adhering to all legal and regulatory requirements and providing patients with the highest quality of care,” the statement read. “Although the rules that dictate when a hospital can accommodate a physician’s request to admit a Medicare patient are complex and evolving, our policy has always been to make those decisions in accordance with government guidelines.”

Guardiola, a registered nurse and a law school graduate, was hired by Banner Health in October 2012 as a director overseeing clinical documentation. She resigned three months later after she determined her efforts to bring “ethical compliance” would be ineffective, according to a statement issued by Kreindler & Associates, a law firm representing Guardiola.

During her brief stint at Banner, Guardiola evaluated Banner’s clinical documentation as well as short-stay inpatient claims.

She discovered that Banner hospitals billed an “inordinate and improper number of short-stay claims, particularly those for expensive cardiac procedures,” according to the statement.

In all, she discovered more than 650 examples of Banner billing Medicare for an inpatient claim even though the patient was admitted and discharged the same day, the statement said.

She also discovered that two hospitals, Banner Boswell and Banner Del Webb, identified some cardiac procedures as urgent rather than elective to prevent claims from being denied, the statement said.

10 thoughts from discussion on 2018 Anti-Kickback and Stark Law issues

https://www.beckershospitalreview.com/legal-regulatory-issues/10-thoughts-from-discussion-on-2018-anti-kickback-and-stark-law-issues.html

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We had a chance to moderate and participate in a webinar with leading colleagues John Harig, Tim Fry, David Pivnick and Brett Barnett regarding key Anti-Kickback Statute and Stark Law issues facing health systems, surgery centers, dialysis providers and other healthcare providers and investors. Below are 10 key thoughts discussed during the webinar as to fraud and abuse issues in play in 2018.

1. The reading and implementation of the “Yates Memo” issued by the U.S. Department of Justice will influence how the government aims to prosecute individuals in addition to companies.

2. The reading of the U.S. Supreme Court’s Escobar decision will influence whether defendants in false claims cases will receive some relief from technical billing violations that are not fundamental or material to the government’s paying of a claim.

3. Regulators and potential buyers are focused on “creative marketing arrangements” by physician practices, often related to laboratory and/or pharmacy arrangements.

4. Government enforcement agencies and potential buyers are focused on physician compensation arrangements, particularly their compliance with the Stark Law.

5. Potential buyers face a challenge in determining how deeply to examine targets’ past practices through billing and coding audits, as well as how to handle the results of billing and coding audits in negotiation of transactions.

6. Private equity buyers face challenges in their evaluation of risk posed by regulatory issues and how to address regulatory risks in a seller’s market.

7. Sellers present the historical legal analysis of fraud and abuse issues during the due diligence process, particularly when the legal analysis is positive, but assumptions underlying the legal analysis do not align with the sellers’ actual operations.

8. The turnover in the U.S. Department of Justice may impact the timing of fraud and abuse prosecutions and settlements.

9. Recoveries by the government resulting from fraud and abuse prosecutions have increased in magnitude. Furthermore, there are more recoveries coming from cases in which the government has not joined in the case with the relator.

10. The wide array of laboratory arrangements and businesses hold implications for fraud and abuse laws.

 

Ex-Cleveland Clinic Innovation executive pleads guilty in $2.7M fraud case, prison time likely

http://www.fiercehealthcare.com/antifraud/ex-cleveland-clinics-innovation-executive-pleads-guilty-2-7m-fraud-case-prison-time?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWkRSalkyTXpOV0V4WkRkayIsInQiOiJHQUVNRTJhUmhhSkpXVk80NkJoOWo5R21nNW5iV0hQS3NxRzc4SUQrbmRyMFwveXlBUFEwRm83TXFUemp0ZE9aNWlBTmYzSVJWb0dzbXV0RTczYnZSTEFMaGhEeFZKYk9LMWJuaXNxUlRUd2V6WEZnZ3lqRUpYaWp6SU0rbUhUd0cifQ==

Money, handcuffs and a stethoscope

The former head of Cleveland Clinic Innovations pleaded guilty Tuesday for his role in defrauding the nonprofit academic medical center out of more than $2.7 million via a shell company.

Gary Fingerhut was arraigned in U.S. District Court and pleaded guilty to one count of conspiracy to commit wire fraud and honest services fraud and one count of making false statements, Crain’s Cleveland Business reports.

Although he won’t be formally sentenced until Jan. 30, Fingerhut’s attorney told the publication that federal prosecutors will ask U.S. District Judge Christopher Boyko for a sentence of between 41 and 51 months in federal prison. He may also be ordered to pay restitution to the Cleveland Clinic.

Fingerhut served as the executive director of the clinic’s innovation arm for two years until an FBI investigation revealed in 2015 that he was involved in a fraudulent scheme with the chief technology officer of a spinoff company to contract with a company that never intended to perform or provide any goods and services. The deal was in violation of Cleveland Clinic’s ethics and compliance policies and requirements, which prohibit employees from receiving any financial benefit from companies the Clinic did business with, and the organization fired Fingerhut.

Federal prosecutors said Fingerhut accepted at least $469,000 in payments in return for not disclosing the fraud scheme, which diverted nearly $3 million from the Clinic.

Fingerhut’s attorney, J. Timothy Bender of Bender, Alexander & Broome in Cleveland, told Crain’s that Fingerhut is very sorry for his role in the fraud scheme.

Swedish Health’s Cherry Hill campus at risk of losing Medicare, Medicaid funding

http://www.beckershospitalreview.com/quality/swedish-health-s-cherry-hill-campus-at-risk-of-losing-medicare-medicaid-funding.html

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CMS is threatening to cut off Medicare and Medicaid funding to Seattle-based Swedish Health’s Cherry Hill campus in 90 days unless it resolves patient safety issues, according to The Seattle Times.

The Washington Department of Health inspected Swedish’s Cherry Hill campus after a February Seattle Times investigative report exposed troubles, including staff members feeling intimidated, patient care concerns and surgeons performing overlapping surgeries.

The state surveyors identified numerous patient safety issues at the Cherry Hill campus, including failure to outline the roles of medical fellows, failure to address behavioral concerns, failure to document surgical tasks of medical residents, failure to listen to staff concerns and failure to track when the attending physician was in the operating room.

“Staff members feared punishment and retaliation for voicing concerns,” the regulators wrote, according to the Seattle Times. “Staff members stated they were frequently bullied and intimidated for voicing concerns about the working conditions in the neurosurgical operating area.”

To keep federal funding for the Cherry Hill campus, Swedish Health must submit a corrective action plan to CMS. Regulators will conduct another survey to ensure the hospital is in compliance with Medicare and Medicaid rules.

Swedish Health said that many of the deficiencies cited have been addressed, according to the report. The system implemented a new policy to ban overlapping surgeries. Additionally, Swedish Health CEO Guy Hudson, MD, insured that the culture of intimidation will be addressed

“We are sorry for what occurred at Swedish Cherry Hill on our watch,” Swedish Health board members told the Seattle Times. “As volunteers, we continue to be deeply committed to our critical governance role in overseeing patient quality and safety, as well as physician credentialing.”