Archive for: Medicaid
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Sebelius: New fraud prevention team will turn up heat
On May 20, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius announced the government's latest tool in the fight against healthcare fraud and abuse—The Health Care Fraud Prevention and Enforcement Action Team (HEAT).
With what appears to be an intended pun, Sebelius said in an HHS press release, "Today, we are turning up the heat on perpetrators who steal from the taxpayers and threaten the future of Medicare and Medicaid."
The HEAT team will consist of senior Department of Justice and HHS employees. Their task will be to strengthen existing fraud prevention tools and investigate new ways to root out and prevent fraud, which, according to Office of Inspector General Chief Counsel Lewis Morris, accounts for about 3%—or more than $60 billion—of the government's annual healthcare investment.
The team will build on demonstration projects created by the HHS Inspector General and the CMS that focus on the vulnerable durable medical equipment (DME) industry. This includes:
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Increasing site visits to potential suppliers to prevent imposters from posing as legitimate DME providers
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Increasing training for providers on Medicare compliance, and offering providers the resources and the knowledge they need to help identify and prevent fraud
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Improving data sharing between CMS and law enforcement to identify patterns that lead to fraud
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Strengthening program integrity activities to monitor and ensure Medicare Parts C (Medicare Advantage plans) and D (prescription drug programs) compliance and enforcement
Holder and Sebelius also announced the expansion of the Medicare Fraud Strike Forces. Since their inception in 2007, the Medicare Fraud Strike Forces have recovered more than $240 million in fraud and abuse cases in South Florida and Los Angeles. The targets for the latest expansion are Detroit and Houston.
The creation of the HEAT team, the expansion of the Medicare Fraud Strike Forces, and the creation of a new healthcare fraud hotline (www.hhs.gov/stopmedicarefraud or 1-800-HHS-TIPS) continue President Barack Obama's push for greater healthcare fraud enforcement. Obama has made strengthening the integrity of the Medicare and Medicaid programs a priority for 2010, allotting $311 million of the $3.4 trillion budget on healthcare fraud and abuse prevention.
DOJ and 16 states join whistleblower lawsuit against Wyeth
The United States, along with 16 states, is joining two whistleblower cases filed against pharmaceutical giant Wyeth for allegedly failing to pay millions in Medicaid rebates, according to a Department of Justice (DOJ) release.
According to the release, between 2000 and 2006, Wyeth gave large discounts to hospitals that purchased Protonix Oral and Protonix IV as a package deal. The DOJ assumes this was done so Wyeth could gain a foothold in the lucrative outpatient medication market. The logic being, patients who received the intravenous version of the stomach acid suppressant (Protonix IV) would also use the oral version once they were discharged.
The problem is Wyeth failed to extend the discount to Medicaid agencies. According to the release, Wyeth knowingly hid the discount program from the Medicaid program in order to avoid paying hundreds of millions in rebate payments, which it was required to pay under the Medicaid Drug Rebate Program.
NY Medicaid fraud unit is nation’s best
The U.S. Department of Health and Human Services (HHS) has selected New York’s Medicaid Fraud Control Unit (NYMFCU) as the top Medicaid fraud unit in the country according to a release issued by New York Attorney General Andrew Cuomo.
The announcement comes a week after Cuomo declared the NYMFCU recovered more than $263 million in civil damages and criminal restitution in 2008, doubling the totals from 2007.
“The New York MFCU's statistical and monetary recovery achievements, in fiscal year 2008, were outstanding and are deserving of special recognition,” HHS stated in the release.
NYMFCU will receive the award June 2 at a ceremony in Washington, D.C.
Florida health plan company enters $80M agreement to avoid fraud charges
On May 5, Tampa-based WellCare Health Plans, Inc. agreed to enter a deferred prosecution agreement (DPA) with the Department of Justice (DOJ) and pay $80 million in restitution and forfeiture to avoid healthcare fraud charges.
After an investigation, more than 200 special agents and investigators from the FBI, OIG, and the Florida Medicaid Fraud Control Unit raided WellCare offices, according to a DOJ release.
The investigation and subsequent raid arose from allegations that WellCare falsely and fraudulently inflated expenditure information submitted to the Florida Medicaid and Healthy Kids programs from mid-2002 through 2006.
In order to avoid a healthcare fraud conviction, WellCare must abide by several DPA requirements, including:
- Paying a civil forfeiture of $40 million
- Paying an additional $40 million in restitution to the Florida Medicaid and Healthy Kids programs
- Retaining and paying an independent monitor to review and monitor business operations
- Cooperating with the government’s ongoing federal and state criminal investigation of former WellCare executives and employees
- Implementing updated policies and procedures to ensure accurate reports of federal and state healthcare program information
- Developing and operating an effective corporate compliance and governance program
Seven California companies indicted in ‘massive’ Medicaid fraud scheme
On March 20, California Attorney General Jerry Brown joined a whistleblower suit that alleges seven companies operating in California overcharged the state for laboratory tests, according to a Department of Justice (DOJ) press release.
A state investigation revealed the companies’ laboratories were provided discounts when paid directly by doctors, patients or hospitals—sometimes up to six times cheaper than what they charged Medicaid for the same tests, according to the DOJ. Brown believes the state can recover hundreds of millions in overpayments from the case.
The press release named Physicians Immunodiagnostic Laboratory, Westcliff Medical Laboratories, Whitefield Medical Laboratory, Seacliff Diagnostics Medical Group, Quest Diagnostics, Laboratory Corp. of America, and Health Line Clinical Laboratories, now known as Taurus West, as the defendants in the case.
Iowa hospitals struggle in hard economic times
On May 20, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius announced the government's latest tool in the fight against healthcare fraud and abuse—The Health Care Fraud Prevention and Enforcement Action Team (HEAT).
With what appears to be an intended pun, Sebelius said in an HHS press release, "Today, we are turning up the heat on perpetrators who steal from the taxpayers and threaten the future of Medicare and Medicaid."
The HEAT team will consist of senior Department of Justice and HHS employees. Their task will be to strengthen existing fraud prevention tools and investigate new ways to root out and prevent fraud, which, according to Office of Inspector General Chief Counsel Lewis Morris, accounts for about 3%—or more than $60 billion—of the government's annual healthcare investment.
The team will build on demonstration projects created by the HHS Inspector General and the CMS that focus on the vulnerable durable medical equipment (DME) industry. This includes:
Holder and Sebelius also announced the expansion of the Medicare Fraud Strike Forces. Since their inception in 2007, the Medicare Fraud Strike Forces have recovered more than $240 million in fraud and abuse cases in South Florida and Los Angeles. The targets for the latest expansion are Detroit and Houston.
The creation of the HEAT team, the expansion of the Medicare Fraud Strike Forces, and the creation of a new healthcare fraud hotline (www.hhs.gov/stopmedicarefraud or 1-800-HHS-TIPS) continue President Barack Obama's push for greater healthcare fraud enforcement. Obama has made strengthening the integrity of the Medicare and Medicaid programs a priority for 2010, allotting $311 million of the $3.4 trillion budget on healthcare fraud and abuse prevention.
NY Medicaid fraud unit is nation’s best
The U.S. Department of Health and Human Services (HHS) has selected New York’s Medicaid Fraud Control Unit (NYMFCU) as the top Medicaid fraud unit in the country according to a release issued by New York Attorney General Andrew Cuomo.
The announcement comes a week after Cuomo declared the NYMFCU recovered more than $263 million in civil damages and criminal restitution in 2008, doubling the totals from 2007.
“The New York MFCU's statistical and monetary recovery achievements, in fiscal year 2008, were outstanding and are deserving of special recognition,” HHS stated in the release.
NYMFCU will receive the award June 2 at a ceremony in Washington, D.C.
Florida health plan company enters $80M agreement to avoid fraud charges
On May 5, Tampa-based WellCare Health Plans, Inc. agreed to enter a deferred prosecution agreement (DPA) with the Department of Justice (DOJ) and pay $80 million in restitution and forfeiture to avoid healthcare fraud charges.
After an investigation, more than 200 special agents and investigators from the FBI, OIG, and the Florida Medicaid Fraud Control Unit raided WellCare offices, according to a DOJ release.
The investigation and subsequent raid arose from allegations that WellCare falsely and fraudulently inflated expenditure information submitted to the Florida Medicaid and Healthy Kids programs from mid-2002 through 2006.
In order to avoid a healthcare fraud conviction, WellCare must abide by several DPA requirements, including:
- Paying a civil forfeiture of $40 million
- Paying an additional $40 million in restitution to the Florida Medicaid and Healthy Kids programs
- Retaining and paying an independent monitor to review and monitor business operations
- Cooperating with the government’s ongoing federal and state criminal investigation of former WellCare executives and employees
- Implementing updated policies and procedures to ensure accurate reports of federal and state healthcare program information
- Developing and operating an effective corporate compliance and governance program
Seven California companies indicted in ‘massive’ Medicaid fraud scheme
On March 20, California Attorney General Jerry Brown joined a whistleblower suit that alleges seven companies operating in California overcharged the state for laboratory tests, according to a Department of Justice (DOJ) press release.
A state investigation revealed the companies’ laboratories were provided discounts when paid directly by doctors, patients or hospitals—sometimes up to six times cheaper than what they charged Medicaid for the same tests, according to the DOJ. Brown believes the state can recover hundreds of millions in overpayments from the case.
The press release named Physicians Immunodiagnostic Laboratory, Westcliff Medical Laboratories, Whitefield Medical Laboratory, Seacliff Diagnostics Medical Group, Quest Diagnostics, Laboratory Corp. of America, and Health Line Clinical Laboratories, now known as Taurus West, as the defendants in the case.
Iowa hospitals struggle in hard economic times
- Paying a civil forfeiture of $40 million
- Paying an additional $40 million in restitution to the Florida Medicaid and Healthy Kids programs
- Retaining and paying an independent monitor to review and monitor business operations
- Cooperating with the government’s ongoing federal and state criminal investigation of former WellCare executives and employees
- Implementing updated policies and procedures to ensure accurate reports of federal and state healthcare program information
- Developing and operating an effective corporate compliance and governance program
Seven California companies indicted in ‘massive’ Medicaid fraud scheme
On March 20, California Attorney General Jerry Brown joined a whistleblower suit that alleges seven companies operating in California overcharged the state for laboratory tests, according to a Department of Justice (DOJ) press release.
A state investigation revealed the companies’ laboratories were provided discounts when paid directly by doctors, patients or hospitals—sometimes up to six times cheaper than what they charged Medicaid for the same tests, according to the DOJ. Brown believes the state can recover hundreds of millions in overpayments from the case.
The press release named Physicians Immunodiagnostic Laboratory, Westcliff Medical Laboratories, Whitefield Medical Laboratory, Seacliff Diagnostics Medical Group, Quest Diagnostics, Laboratory Corp. of America, and Health Line Clinical Laboratories, now known as Taurus West, as the defendants in the case.
Iowa hospitals struggle in hard economic times
The Iowa Hospital Association (IHA) reports declines in service areas and increases in charity care for Iowa hospitals. Considering all factors, Iowa hospitals’ overall margins have fallen from 5.5% in 2007 to -9.6% at the end of 2008.
Kirk Norris, the President and CEO of the IHA, comments that, unlike other businesses, hospitals must provide their services 24 hours a day every day, despite their customers’ inability to pay.
Another factor contributing to the hospitals’ economic hardships, according to the IHA, are reimbursement rates from Medicare and Medicaid. These programs together make up about 60% of Iowa hospital revenue, and in 2008 Iowa hospitals lost more than $275 million to the two programs.
Hospitals are among the largest employers in the counties where they are located, and Norris calls for the government to take a close look at the burden programs such as Medicare and Medicaid are placing on them.
Source: Iowa Hospital Association
Hospitals must submit Medicare Advantage claims as far back as October 2005 By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro, Inc.
Last week, CMS published Transmittal 1695 to the Claims Processing Manual, reaching back to FY 2006 to include Medicare Advantage (MA) Plan members in the Disproportionate Share Hospital (DSH) calculation. CMS calculates a DSH adjustment to DRG payments for hospitals serving a disproportionate share of low income patients.
By regulation, low-income patients include certain Medicaid patients (Medicaid portion) and certain Medicare patients (Medicare portion). The Medicare portion is a ratio of Medicare Part A patients receiving Social Security Income (SSI) (disabled) divided by the total Medicare Part A patients. The Medicare portion includes MA members because they are eligible for Medicare Part A, even though the payment is being made through a MA plan. The effect of including MA members may be positive or negative for hospitals, depending on how the addition of the MA members affects the overall Medicare portion ratio.
This issue may sound familiar because in July of 2007 CMS published Transmittal 1311 that gave instructions for hospital to include MA members in their Disproportionate Share calculation for FY 2007. Transmittal 1695 requires hospital who received DSH to go back as far as FY 2006 and submit MA plan member data. The affected providers have a limited time frame to submit the claims data for FY 2006: from the implementation date, July 6, 2009, through November 30, 2009.
The process for submitting MA member data entails submitting a separate claim to the MAC/FI with condition code 04 (Information Only) and the Medicare Beneficiary’s HICN. CMS has instructed contractors to override timely filing edits for these claims. They have also turned off the Medicare Summary Notice to the patient.
NOTE: Teaching hospitals are not affected by this requirement because they would have already submitted a claim for Indirect Medical Education payment with condition code 04 and 69, which would allow CMS to account for the MA plan members in their DSH calculations.
