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

Image result for fraud and abuse

 

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

Image result for Swedish Health's Cherry Hill campus at risk of losing Medicare, Medicaid funding

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.”

6 things keeping supply chain leaders up at night

http://www.beckershospitalreview.com/supply-chain/6-things-keeping-supply-chain-leaders-up-at-night.html

Related image

East Lansing-based Michigan State University partnered with the APICS Supply Chain Council to identify critical issues on the minds of supply chain leaders.

To compile the report, the groups interviewed leaders from more than 50 firms across the globe and asked them: “What keeps you awake at night?”

Here are the six most common issues on supply chain leaders’ minds, as identified in the report.

1. Capacity or resource availability. Many companies expecting market growth cited managing capacity issues as a main priority. They often wanted to avoid outsourcing and identified challenges to maximize their facilities’ capacity by replacing old equipment, among other activities.

“We’ve implemented a supply chain for a point in time,” one leader said, according to the report. “However, a supply chain is a living, breathing thing, and one needs to think about it as dynamic and impermanent. Is there a point where the supply chain becomes inappropriate for where we’re going, and we need to build a different kind of supply chain?”

2. Talent. Participating companies also described the struggle to find and keep good supply chain talent.

“The competition for talent is much higher [than it’s ever been],” said another participant in the report. “You go out to the market, and it’s one of those ironies. Right now, you put a job description out there, and you hear about 8 percent unemployment. However, I can’t find an industrial engineer worth his salt — you know, someone who can really think about strategy and think about [profit and loss statements] and drive change.”

3. Complexity. Some firms faced issues with their products becoming more complex and found it difficult to manage the increasing amount of stock keeping units.

“We’ve started building different types of products, completely new types of products. Whether it’s low or high volume, it creates another level of complexity,” said one leader in an interview.

4. Threats or challenges. A lot of supply chain leaders are worried about managing supply chain risk, and many mentioned the importance of continuity planning.

“I worry about supply risks in general, whether it’s from natural disasters or things like … a troubled supplier or a variety of issues with the whole supply chain risk piece,” one participant told researchers. “Partly that’s because that stuff is hard to control. You can try to proactively mitigate the downsides, but that’s just hard to control.”

5. Compliance. Participants cited numerous compliance issues like product regulation, trade controls and continually changing regulations, according to the report. Many leaders said they were struggling to keep up with both the high volume of regulations and how much they constantly changed.

“[The changes] are really causing us to spend a lot of money and a lot of our time. It is sucking up a huge amount of our information technology dollars and resources to be able to be compliant with those regulations,” said one study participant.

6. Cost or purchasing issues. While pressure to rein in costs is a focus for companies in every industry, it’s a top priority for healthcare and drug companies amid the shift toward value-based care, according to the report.

“Everything in healthcare is submitted through insurance for reimbursement,” one leader said. “The government won’t pay you any more to treat your patients, so you better get [the payout from] your suppliers. Well, we’re the supplier they’re coming after.”

To view the complete report, click here.

3 factors that will tank your workforce management

http://www.healthleadersmedia.com/hr/3-factors-will-tank-your-workforce-management?spMailingID=9754012&spUserID=MTMyMzQyMDQxMTkyS0&spJobID=1021982472&spReportId=MTAyMTk4MjQ3MgS2

Image result for workforce management strategy

“No more overtime will be approved!” How many times have we heard declarations like this in an attempt to control labor costs? Considering that labor costs are a hospital’s largest expense exceeding 50% of their operating budgets, it’s no wonder that remarks like this are frequently heard. Healthcare providers have spent millions of dollars on analytics and other systems to find a way to get these costs under control. Yet, they still do not have clear insights into their labor costs and are unable to implement sustainable programs to manage and control costs. I’m going to look at three areas that limit a healthcare provider’s ability to manage their workforce in a way that optimizes labor, controls costs and drives outcomes.

New era of healthcare fraud investigations puts spotlight on the C-suite

http://www.beckershospitalreview.com/legal-regulatory-issues/new-era-of-healthcare-fraud-investigations-puts-spotlight-on-the-c-suite.html

Image result for DOJ Yates Memo

More and more, the government is holding individuals — not just the organizations they work for — responsible for fraud.

Traditionally, healthcare companies were only expected to provide information about the underlying factual situation in a fraud investigation. However, these investigations have become more complicated, as the Department of Justice has taken a strong stance on pursuing healthcare executives involved in fraud cases to hold them personally responsible.

Venson Wallin, managing director of BDO’s Healthcare Advisory practice, recently spoke withBecker’s Hospital Review about the shift in individual accountability standards and steps hospital and health system executives can take to protect themselves from liability.