The Medicare Fraud Strike Force working with the Department of Justice has been particularly active in Detroit and in Miami, two of the eight cities singled out for special attention by the government for fraud of the government. There seems to be some kind of special axis between Detroit and Miami perhaps reflected by the recent by the migration of Cuban emigres Caridad and Clara Guiarte, who operated a medicare fraud scheme in Miami before moving to Dearborn, Michigan when things got too hot, both literally and figuratively, in Miami. They bilked the government out of millions of dollars for providing (or not providing as the case may be) infusion therapy for treatment of the AIDS virus. Most of these schemes involve paying kickbacks to “patients” for the use of their Medicare numbers and money laundering. The sisters Guiarte were recently sentenced to 14 years in prison following their arrests in Columbia. Interesting Medicare continued to pay for a therapy that has been obsolete for a decade due to the development of new antiretroviral drugs.
According to a GAO report in 2005 approximately seventy five percent of those physicians providing concierge medicine services do not opt out of Medicare, but provide some services either as a participating or non-participating physician. Those physicians must be very careful to assure that they do not charge concierge customers for any service that might be otherwise covered by Medicare which can create a potential claim for over-billing for medicare services in violation of the False Claims Act.
There is a fair amount of confusion afoot concerning the obligation or not of physicians to accept Medicare patients. There is no requirement that any physician accept Medicare patients or refrain from limiting the number of Medicare patients accepted into the physician’s practice. There are circumstances when it may be in the best interest of a physician to “opt out” of Medicare. The growth of concierge medicine in some respects makes it safer for physicians to “opt out” of Medicare in order to avoid stepping afoul of the Medicare fee limitations by charging for services that might be construed by CMS or the OIG as being extra contractual charges which might implicate the federal false claim statute. According to 2005, General Accounting Office Survey of providers of concierge medicine, only about 25% of them had opted out and were practicing on the cash only high wire without the Medicare safety net.
Shocking though it might be, the U.S. Senate Finance Committee discovered recently that companies primarily organized to provide home health care services to Medicare recipients tend to tailor their care to meet government payment incentives. The care tends to follow the money to the surprise of almost no one except perhaps the finance committee. Three large home health companies and their patterns of distribution of services were reviewed by the committee. The committee found that Gentiva Health Services, Amedisys,Inc., and LHC Group, Inc. encouraged employees to make enough home visits to trigger incentive bonus payments offered by the government.
Hill-Rom Company, Inc., a Durable Medical Equipment Supplier has agreed to settle a Qui Tam Medicare fraud case for $41.8 Million dollars. The suit, United States of America, ex. rel. Laurie Salmons and Lisa Brocco v. Hill-Rom Company, Inc., No. 3:05 CV 210 was filed in the U.S. District Court for the Eastern District of Tennessee in 2005. This was a citizen private attorney general case brought on behalf of the U.S. Government under the federal False Claims Act, 31 U.S.C. 3729 et seq. The plaintiffs, nurses and former employees of Hill-Rom will share millions of dollars in the settlement, the majority of which will go to the federal treasury.
Recognizing the critical health care need for accurate historic patient health records, the Obama administration has developed what it calls a “Blue Button” download initiative at the Department of Veteran Affairs, CMS and HHS. These are all programs that permit patients to go on-line and download their own medical records that they can share with their providers, caregivers and trusted others. Some of these programs are now operational. In the lead is the VA ( www.myhealth.va.gov ) where approximately 60,000 veterans have already accessed their records. Medicare recipients can also access their records now at www.mymedicare.gov . Only about 5,600 have done so. There are about 47 million medicare recipients and 1 million veterans.
The Wall Street Journal reported today that United Health Group as agreed to acquire a Monarch Healthcare, an Irvine California physician group including approximately 2300 physicians in a range of specialties. The acquisition is by United’s subsidiary Optum Health. The fluidity and uncertainties of health care financing and strategy has led to a number of interesting events with the merger of providers with the insurance function in different and yet reminiscent echoes of managed care arrangements of the past. The Monarch deal in California in somewhat encumbered by the arcane corporate practice of medicine restrictions. The situation here would likely involve the purchase of some hard assets and a long term contractual relationship with an independent practice association.
The United States has undergone a massive redistribution of wealth in the last 30 years. In 1980 the top 1 percent of taxpayers reported 8.5 % of the nations reported income to the Internal Revenue Service. In 2008, the top 1 percent of taxpayers reported receiving 20% of the nation’s income. This and the following 31 other statistics provide an interesting foundation to review the PPACA and its alternatives.
Whether or not an insurance company will provide coverage for telemedicine services or not is generally controlled by the company’s interpretation of its policies. Many insurance companies do voluntarily provide telemedicine coverage. Some insurance policies require “face to face” provision of services or specifically exclude telemedicine coverage. In most states the issue of telemedicine coverage is left to the discretion of the insurance companies in their plan designs.
Recovery Audit Contractors (RACs) are in the process of saddling up for the nationwide roll out of their Medicare payment recoupment mission. Here are twenty-five recommended proactive steps to circle the wagons and defend the RAC threat.
1. Develop and implement a written audit defense plan- the government bounty hunters are coming your way and they will be looking for the low lying fruit.
2. Select an audit team or responsible persons depending upon the size of your organization. Including if appropriate internal audit, billing and coding, medical records, risk management and the CFO.
3. Assign specific team member responsibilities in dealing with anticipated audit issues.
4. Consider running an internal pre-audit to identify vulnerabilities such as “medical necessity” and “duplication of services.”
