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$163 million squeezed from Medicare by organized crime, largest case of its kind

The largest Medicare fraud operation conducted by a single group was recently taken down, the Department of Justice announced earlier this week. The accused individuals allegedly stole the identities of physicians and Medicare beneficiaries to set up shadow clinics to bill for unnecessary services and/or procedures that were never performed.

Here are some of the statistics from the case:

  • 73 defendants were charged with various healthcare fraud-related crimes
  • $163 million in fraudulent billing was sent to Medicare
  • 118 alleged shadow clinics submitted Medicare charges
  • 25 states housed the shadow clinics

“The [accused] perpetrated a large-scale, nationwide Medicare scam that fraudulently billed Medicare for more than $100 million of unnecessary medical treatments using a series of phantom clinics,” said Kevin Perkins, FBI Assistant Director of the Criminal Investigative Division, in a press release. “We want to restore the confidence in the nation’s health care system and assure practitioners we will not stand by and let their identities be used for criminal gain.”

This case highlights the important work MSPs do in verifying Medicare and Medicaid sanctions to ensure the proper sanctions are rendered and to stop identity fraud in its tracks.

Florida pediatricians switch hospitals, reasons unknown

A group of 10 Florida pediatricians have switched hospital affiliations, but the reasons behind the move remain murky, according to an October 7, article. The physicians previously held privileges at Fort Walton Beach Medical Center (FWBMC), but as of October 1, they are exclusively seeing patients at White-Wilson Medical Center.

According to FWBMC the physicians left to focus on their primary care role, but other sources told there were other factors at play. Specifically, the pediatricians objected to FWBMC’s plans for pediatric emergency care services that they felt couldn’t be supported by the organization’s pediatric resources.

Question: Do you think the hospitals involved should fully disclose to the general public the reasons behind the physician’s move, or should the organizations’ let the public know a change has occurred and leave it at that? How would your medical staff handle the situation? Leave your answer in the comment boxes below.

Live! from NAMSS, meet Mary Baker, DHA, CPMSM, CPCS

Greetings from beautiful Orlando, Florida! Today was the first day of the annual National Association Medical Staff Services (NAMSS) conference. It was also the first day of work for the newest member of our Greeley consulting team, Mary Baker, DHA, CPMSM, CPCS. Check out the video clip below to get to know Mary. It was shot live from the NAMSS conference (please excuse the background noise).

New technology news: FDA reopens whistleblower investigation on medical devices

A group of scientists at the FDA claiming their managers pressured them to approve some medical devices despite their concerns are having their complaints reexamined, according to a September 30, Wall Street Journal article.

Earlier this year, the Department of Health and Human Services dismissed the allegations of criminal charges against the managers. Now the matter is being reinvestigated as potential administration violations by the managers.

Click here to read more or to forward on to your new technology review committee.

Posing as a practitioner, arrested as a criminal

MSPs are great at spotting red-flags on applications and ensuring that criminals posing as doctors don’t make their way into hospitals. However, some just skip the application process and show up dressed for work.

Police in Danville, VA arrested a man last week wearing a white coat embroidered with “Pediatric Physician’s Assistant Resident.” He was charged with engaging in practicing the profession or occupation of medicine, without holding a valid license, according to a news report.

It’s another reminder for medical staffs to keep their eyes open for practitioner imposters, both in the credentialing process and in their hallways.

Home births on the rise, but not always with the help of hospital-privileged practitioners

Hospital-privileged practitioners may face competition from their peers at a hospital across town or from a specialty-focused ambulatory care organization. Few face competition from unlicensed professionals working in a home setting—except for those practitioners offering labor and delivery services.

Home births increased 5% from 2004 to 2005, and remained steady at about 25,000 in 2006 (the last year for which figures are available) according to data from the National Center for Health Statistics, published in the September 23 New York Times.

Although these figures don’t necessarily mean that labor and delivery physicians in hospitals will suddenly become low-volume providers, there is a potential for a shift in their services. Groups such as the American College of Obstetrics and Gynecology, American Medical Association, and some state medical associations oppose home births assisted by unqualified practitioners due to the medical risks.

ESAR-VHP launches new website for disaster credentialing

The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) launched a new website that allows interested providers to register in advance to assist in emergency situations, such as a natural disaster. MSPs can use the information collected by this website to help issue disaster privileges. (Don’t let the terminology confuse you. The Joint Commission uses the term emergency privileges to mean privileges issued for an urgent, specific patient care need. The accreditor uses the term disaster privileges to mean privileges usually assigned to a number of providers to provide services during a wide-reaching emergency, such as a natural disaster.)

Below is a chart from the volunteer sign-up page explaining the different categories volunteers fall into. MSPs may assign disaster privileges to volunteers who meet Level 1 criteria.


Explore the world through credentialing

I recently got an e-mail from Guenther Baerje, BSIT, CPMSM, HACP, director of medical staff management at  Good Samaritan Hospital in Los Angeles, describing how his efforts to credential physicians from foreign countries has led to a hobby in stamp collecting. Here’s what he had to say:

“I’ve had more than one doctor tell me that I would never get primary source verification from his or her home  country, but with the Internet, I’ve collected many. This led me to start collecting some of the more interesting stamps from foreign countries. I had enough to do a mini collage. I framed it and put where the docs wait in our office, and have had enough compliments on it, that I thought I’d share.”

Family medicine providers top list of physician placement trends

Which types of providers are the most in-demand at your organization?

Do the specialties of family medicine, emergency medicine, and orthopedic surgery ring any bells? Those are the top three specialties in-demand for the 2nd quarter of 2010 according to The Physician Recruiting Standard, published by The Delta Companies.

Compared with the same quarter last year, the top three specialties in-demand were family medicine, general surgery, and obstetrics/gynecology.

Click here to download a free copy of the report, and learn about the physician placement trends that may affect your organization.

Cardiologist collected $13m from insurance billing scam

When MSPs conduct criminal background checks on practitioners or search for them on the OIG’s List of Excluded Individuals/Entities, chances are the results will reveal an honest application. However, that doesn’t mean practitioners aren’t committing insurance fraud.

Case in point: Sushil Sheth, MD, cardiologist from Chicago who was recently found guilty of stealing $13 million from Medicare and 30 other insurance companies over a five year period. Law officials say Sheth held privileges at three hospitals where he obtained patient information that he used for false billing purposes.

Click here to read more about the case which highlights the importance of conducting background checks.