Pennsylvania health system, CEO will pay $12.5M to resolve billing probe

https://www.beckershospitalreview.com/legal-regulatory-issues/pennsylvania-health-system-ceo-will-pay-12-5m-to-resolve-billing-probe.html?origin=cfoe&utm_source=cfoe

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Allentown, Pa.-based Coordinated Health and its founder and CEO Emil DiIorio, MD, have entered into an agreement with the federal government to settle False Claims Act allegations, according to the Department of Justice.

The settlement resolves allegations that Coordinated Health inflated payments from federal payers by unbundling claims for reimbursement for orthopedic surgeries, including many for total joint replacement, from 2007 through mid-2014.

Instead of stopping the illegal unbundling, Dr. DiIorio changed how he wrote operative reports to enable Coordinated Health billers to maximize improperly unbundled reimbursements, according to the Justice Department.

Two outside coding consultants identified the improper unbundling during audits in 2011 and 2013 and told top Coordinated Health executives about the problem. “Motivated by its bottom line, Coordinated Health simply ignored the consultants’ recommendations and continued abusing Modifier 59 to improperly unbundle orthopedic surgery claims until mid-2014,” states a Justice Department press release.

Coordinated Health will pay $11.25 million and Dr. DiIorio will pay $1.25 million to settle the allegations. In addition to the monetary settlement, Coordinated Health entered into a corporate integrity agreement with HHS that will require monitoring of its billing practices for five years.

Regarding the settlement, Coordinated Health released the following statement: “We are pleased to have come to a resolution with the federal government regarding allegations of our past use of a specific Medicare billing modifier, involving a complex Centers for Medicare and Medicaid Services rule, which does not relate to the quality of patient care. We have already updated our billing practice to resolve the issue in question, and have taken a number of decisive actions to reduce the potential for issues in the future. Our focus has been and always will be providing the best possible patient care in the communities we serve.”

 

6 Michigan physicians charged in $464M billing fraud scheme

https://www.beckershospitalreview.com/legal-regulatory-issues/6-michigan-physicians-charged-in-464m-billing-fraud-scheme.html?origin=rcme&utm_source=rcme

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A grand jury in Michigan returned a 56-count indictment Dec. 4 that charges six physicians in a $464 million healthcare fraud scheme, according to the Department of Justice.

Rajendra Bothra, MD, owner and operator of a pain clinic in Warren, Mich., and five physicians who worked at the clinic are accused of prescribing patients opioid pain medication to get them to come in for office visits. During the office visits, the physicians allegedly subjected the patients to unnecessary treatment, including facet joint injections. The physicians “sought to bill insurance companies for the maximum number of services and procedures possible with no regard to the patients’ needs,” the Justice Department said in a press release.

The fraud scheme, which occurred between 2013 and November 2018, allegedly involved more than 13 million unlawfully prescribed opioid prescription drugs.

“The damage that opioid distribution has done to our community and to the United States as a whole has been devastating,” said U.S. Attorney Matthew Schneider. “Healthcare professionals who prey on patients who are addicted to opioids in order to line their pockets is particularly egregious. We will continue to prosecute such individuals who choose to violate federal law and their ethical oaths.

 

Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks

The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.

The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.

With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.

From hundreds of letters sent to the government by health care executives and lobbyists in the last few weeks, some themes emerge: Federal laws prevent insurers from rewarding Medicare patients who lose weight or take medicines as prescribed. And they create legal risks for any arrangement in which a hospital pays a bonus to doctors for cutting costs or achieving clinical goals.

The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries. The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.

Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.

“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.

Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.

These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.

Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.

The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.

The Trump administration is calling its effort a “regulatory sprint to coordinated care.”CreditSarah Silbiger/The New York Times.

Health care providers can be fined if they offer financial incentives to Medicare or Medicaid patients to use their services or products. Drug companies have been found to violate the law when they give kickbacks to pharmacies in return for recommending their drugs to patients. Hospitals can also be fined if they make payments to a doctor “as an inducement to reduce or limit services” provided to a Medicare or Medicaid beneficiary.

Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”

Almost every week the Justice Department files another case against health care providers. Many of the cases were brought to the government’s attention by people who say they saw the bad behavior while working in the industry.

“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

But the laws are complex, and the stakes are high. A health care provider who violates the anti-kickback or self-referral law may face business-crippling fines under the False Claims Act and can be excluded from Medicare and Medicaid, a penalty tantamount to a professional death sentence for some providers.

Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community.

Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.

AstraZeneca, the drug company, said that older Americans with drug coverage under Part D of Medicare “often face prohibitively high cost-sharing amounts for their medicines,” but that drug manufacturers cannot help them pay these costs. For this reason, it said, the government should provide legal protection for arrangements that link the cost of a drug to its value for patients.

Even as health care providers complain about the broad reach of the anti-kickback statute, the Justice Department is aggressively pursuing violations.

A Texas hospital administrator was convicted in October for his role in submitting false claims to Medicare for the treatment of people with severe mental illness. Evidence at the trial showed that he and others had paid kickbacks to “patient recruiters” who sent Medicare patients to the hospital.

The owner of a Florida pharmacy pleaded guilty last month for his role in a scheme to pay kickbacks to Medicare beneficiaries in exchange for their promise to fill prescriptions at his pharmacy.

The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million.

The line between patient assistance and marketing tactics is sometimes vague.

This month, the inspector general of the Department of Health and Human Services refused to approve a proposal by a drug company to give hospitals free vials of an expensive drug to treat a disorder that causes seizures in young children. The inspector general said this arrangement could encourage doctors to continue prescribing the drug for patients outside the hospital, driving up costs for consumers, Medicare, Medicaid and commercial insurance.

 

 

 

Healthcare Triage: A Lyft to the Hospital: Can Ride Sharing Replace Ambulances?

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An ambulance ride of just a few miles can cost thousands of dollars, and a lot of it may not be covered by insurance. With ride-hailing services like Uber or Lyft far cheaper and now available within minutes in many areas, would using one instead be a good idea?

Perhaps surprisingly, the answer in many cases is yes. That’s the topic of this week’s HCT.

 

 

 

Feds claim Kansas physician involved in $30M billing fraud scheme

https://www.beckershospitalreview.com/legal-regulatory-issues/feds-claim-kansas-physician-involved-in-30m-billing-fraud-scheme.html

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A Kansas physician and Hutchinson (Kan.) Clinic are defendants in a False Claims Act case the federal government recently intervened in, according to the Great Bend Tribune.

The government alleges Mark Fesen, MD, and Hutchinson Clinic billed Medicare and Tricare for more than $30 million for medically unnecessary medications and treatments, including chemotherapy.

The 45-page federal complaint provides nine examples of patients who received unnecessary treatments.

“These patient examples are not isolated examples, but instead representative examples of the medically unnecessary services Fesen and Hutchinson Clinic repeatedly billed to Medicare and Tricare,” states the complaint. “This is supported by the clinic’s own internal audits that found widespread problems with Fesen’s chemotherapy regimens, and particularly his use of Rituxan.”

A clinical pharmacist who worked in Hutchinson Clinic’s oncology department from 2007-14 originally brought the allegations against Dr. Fesen and the clinic under the qui tam, or whistle-blower, provisions of the False Claims Act.

 

 

7 latest healthcare industry lawsuits, settlements

https://www.beckershospitalreview.com/legal-regulatory-issues/7-latest-healthcare-industry-lawsuits-settlements-100518.html?origin=cfoe&utm_source=cfoe

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From the U.S. Equal Employment Opportunity Commission suing a Tennessee health system over its flu shot policy to a Montana health system paying $24 million to settle a whistle-blower lawsuit, here are the latest healthcare industry lawsuits and settlements making headlines.

1. EEOC sues Saint Thomas Health over mandatory flu shot policy
The U.S. Equal Employment Opportunity Commission filed a lawsuit against Nashville, Tenn.-based Saint Thomas Health Sept. 28, alleging Murfreesboro, Tenn.-based Saint Thomas Rutherford Hospital violated federal law by ordering an employee to receive a flu shot despite his religious belief

2. Montana hospital pays $24M to settle ex-CFO’s whistle-blower suit
Kalispell (Mont.) Regional Healthcare System and six subsidiaries and related entities agreed to pay the federal government $24 million to resolve allegations they violated the False Claims Act, Stark Law and the Anti-Kickback Statute.

3. DaVita resolves false claims, whistle-blower allegations for $270M
HealthCare Partners Holdings, which does business as DaVita Medical Holdings, will pay $270 million to settle False Claims Act violations and a whistle-blower lawsuit.

4. AmerisourceBergen to pay $625M to settle civil fraud charges linked to repackaging scandal
Drug wholesaler AmerisourceBergen will pay $625 million to resolve allegations that the company improperly distributed tampered and repackaged drugs.

5. Kansas physician awarded $29M in wrongful termination suit
A jury awarded a Kansas emergency physician $29 million for his lawsuit claiming he was wrongfully terminated by the emergency room staffing company he worked for after voicing concerns about the organization’s business practic

6. Disability advocacy firm sues Arizona hospital over access to patients
The Arizona Center for Disability Law filed a lawsuit Sept. 12 against Phoenix-based Arizona State Hospital, claiming hospital officials violated federal law by refusing to provide the center with access to the facility, patients and their records.

7. Louisiana health system stuck in antitrust suit brought by ex-hospital operator, health plan
BRF, a hospital operator in Shreveport, La., and the regional Vantage Health Plan are surging forward with an antitrust lawsuit against Shreveport-based Willis-Knighton Health System, even though BRF left the hospital business Oct. 1.

 

6 latest healthcare industry lawsuits

https://www.beckershospitalreview.com/legal-regulatory-issues/6-latest-healthcare-industry-lawsuits-091018.html

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From national healthcare organizations refiling a lawsuit over 340B drug pricing program cuts to a Georgia physician accused of submitting thousands of false claims to Medicare, here are the latest healthcare industry lawsuits making headlines.  

1. CHS, Quorum say investors weren’t duped into buying stock at inflated prices
Franklin, Tenn.-based Community Health Systems and Brentwood, Tenn.-based Quorum Health urged a federal judge not to grant class certification in a shareholder lawsuit alleging Quorum’s stock was trading at an inflated price after its spinoff from CHS.

2. Georgia physician allegedly submitted 4,500 false claims for unnecessary lead poisoning treatments
Federal investigators allege Charles Adams, MD, a physician in Fort Oglethorpe, Ga., injected thousands of patients with a lead poisoning treatment they didn’t need, and billed the government $1.5 million for medically unnecessary treatments.

3. Premera Blue Cross accused of destroying evidence in data breach case
The plaintiffs in a class-action lawsuit against Premera Blue Cross, which involves a 2014 data security incident, claim the payer “willfully” destroyed evidence that would have provided details of the breach.

4. Hospitals refile lawsuit against CMS over $1.6B in 340B cuts
The American Hospital Association, along with several other national healthcare organizations and hospitals, refiled their lawsuit against HHS to reverse Medicare payment cuts for drugs purchased through CMS’ 340B drug pricing program, the AHA announced Sept. 5.

5. Medical center owners allegedly double billed insurers, altered patient records as part of $80M scheme
Four people were charged in an $80 million Medicare fraud scheme that involved providing unnecessary medical treatment to patients.

6. Physician imposter allegedly diagnosed patient at California hospital
A 23-year-old man is accused of impersonating a physician at California hospitals.