Fighting Medicare and Medicaid Fraud, Waste & Abuse · Medical LLC (Arriva) and its parent Alere Inc. (Alere) submitted or caused false claims to the Medicare program for medically

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Fighting Medicare and Medicaid Fraud, Waste & Abuse

Laura Long, Medicare Operations Lead

April 2019

NCI Proprietary Information 2 www.nciinc.com

Agenda

• Role of Unified Program Integrity Contractors (UPIC)

• Fighting Fraud Together

• Fraud Trends

• Reporting Suspected Medicare Fraud

• What if My Claims are Audited by AdvanceMed?

• Summary

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Unified Program Integrity Contractor (UPIC) Role • The Centers for Medicare & Medicaid Services (CMS) transitioned from 7 Zone Program Integrity

Contractors (ZPICs) to 5 Unified Program Integrity Contractors (UPICs)

• Goal: achieve enhanced detection and prevention of fraud, waste and abuse across the Medicare and Medicaid programs by:

Consolidating Medicare and Medicaid program integrity activities previously handled by separate contractors;

Increasing sharing and coordination of information among Medicare & Medicaid partners;

Emphasizing timely administrative actions; and

Strengthening the data matching across the Medicare and Medicaid programs to expand the view of provider/supplier billing patterns.

• UPIC Midwest – AdvanceMed

11 states (MI, OH, KY, IN, IL, WI, MN, IA, MO, NE, KS)


UPICs: Who and Where

AdvanceMed

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UPIC Primary Functions

Three primary areas within the UPIC: Investigations/Audits, Data Analysis, and Medical Review

• Reactive and proactive identification of potential fraud, waste, and abuse

Proactive and reactive data analysis

Evaluation of leads/complaints

Referrals from law enforcement

Referrals from MACs and other Medicare contractors

• Support for law enforcement during investigation and prosecution of healthcare fraud cases

Medical review

Data analysis

Overpayment determination

Subject matter expert testimony

Fighting Fraud Together UPIC & MAC Collaboration

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UPIC and MAC Collaboration

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AdvanceMed works closely with MACs to identify and prevent fraud, waste, and abuse

AdvanceMed’s Medical Review team works closely with MAC to ensure a consistent approach

Uses Medicare-recognized references as the basis for reviews: LCDs, the Program Integrity Manual (PIM), and other CMS guidance

Coordination calls held periodically with Medical Directors, Medical Review Managers and staff from both contractors


CGS’s Role in Preventing Fraud, Waste, and Abuse

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Conduct initial complaint screening

Collect information and refer complaints and internally-identified leads to AdvanceMed

Provide information as requested (e.g., Provider Enrollment applications, previous educational contacts) in support of AdvanceMed’s cases, investigations, and Law Enforcement requests for information

Facilitate implementation of pre-payment edits/reviews

Facilitate implementation of Administrative Actions, including:

Revocation of billing privileges

Payment suspension

Overpayment recovery

Monitor and update sanctioned providers

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AdvanceMed’s Role in Preventing Fraud, Waste, and Abuse

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Evaluate and prioritize leads (proactive and reactive) and complaints

Take actions to develop investigations:

Analyze data

Interview patients/staff

Visit facility or provider’s office

Conduct medical review in support of Program Integrity investigations/cases

Support law enforcement investigations

Prepare education materials for providers related to potential fraud and abuse

Identify and notify CMS concerning program vulnerabilities and emerging fraud schemes

What if My Claims are Audited by AdvanceMed?

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If Claims from Your Office are Selected for Review AdvanceMed may contact you:

By phone to discuss current practice locations and other general information

By letter requesting medical records for a list of patients for specific dates of service

By a site visit (announced or unannounced)

If selected for review, be sure to:

Send requested medical records by specified date to specified address

Note: AdvanceMed’s document processing center is located in Virginia.

Include all requested portions of records requested: progress notes, PT notes, physician orders, etc.

Submit all information that supports the service billed

Cooperate with AdvanceMed team if there is an on-site audit

You may ask for identification


If Claims from Your Office are Selected for Review • Substantiated allegations result in the potential for a variety of administrative actions, including:

Education regarding proper billing and/or documentation

Medicare Overpayment Determination

The first “educational” letter from the UPIC and give examples of errors found and total of the overpayment

A second “overpayment” letter will come from the MAC, CGS, and will contain information about how to submit the refund and also provides information on your appeal rights

Medicare Payment Suspension – with CMS approval

Medicare Revocation – with CMS approval

Referral to State Licensure Board

Referral to Quality Improvement Organization (QIO)

Referral to Law Enforcement (provider will not be made aware of this action)

• AdvanceMed monitors providers after the implementation of an administrative action to ensure compliance with Medicare policies and regulations

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Fraud Trends


Appalachian Regional Prescription Opioid Strike Force

Oct. 25, 2018: Justice Department’s Criminal Division announced the formation of the Appalachian Regional Prescription Opioid Strike Force (ARPO Strike Force)

• Joint law enforcement of the Health Care Fraud Unit in the Criminal Division’s Fraud Section (HCF Unit), the U.S. Attorney’s Offices for nine federal districts in five states, law enforcement partners at the FBI, U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) and U.S. Drug Enforcement Administration (DEA).

• Mission: Identify and investigate health care fraud schemes in the Appalachian region and surrounding areas, and to effectively and efficiently prosecute medical professionals and others involved in the illegal prescription and distribution of opioids.

• States: Tennessee, Kentucky, West Virginia, Ohio, and Northern Alabama

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Home Health

Improper patient recruiting tactics

Keeping patients on home health after skilled need or homebound status no longer exists

Seeking physician assessments and orders for home health services from “recruited” physician rather than the patient’s primary care physician

Requests for Anticipated Payment (RAPs) submitted; no services or only first service provided

February 27, 2019, Florida: the owner of a Home Health Agency was sentenced to 87 months in prison and ordered to pay $8,603,859 in restitution. The owner admitted that he paid kickbacks and bribes to his co-conspirators in exchange for home health services prescriptions and the referral of Medicare beneficiaries to his HHA. He also billed Medicare for physical therapy services performed by another individual on behalf of licensed therapists despite knowing that she was not licensed to render those services to the Medicare beneficiaries.


Hospice

Improper patient recruiting tactics

Informing patients that “hospice is not just for terminal diagnoses”

Asking physician to sign documents attesting that a patient is terminal, without the physician ever having examined the patient

February 2, 2018, Pennsylvania: a privately owned for-profit hospice company and its owner and Chief Executive Officer agreed to pay the United States $1,240,000 to resolve allegations that the company had fraudulently billed Medicare and Medicaid for hospice services for patients who were ineligible for hospice.

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Skilled Nursing Facilities Providing unnecessary levels of physical therapy to patients in order to

increase the RUG code, which increases reimbursement

June 6, 2017, Pennsylvania: a health care company agreed to pay the federal government $53,639,288.04, including interest, to settle six federal lawsuits and investigations alleging that its companies and facilities violated the False Claims Act by causing the submission of false claims to government health care programs for medically unnecessary therapy and hospice services, and grossly substandard nursing care. Among other things, the settlement also resolves allegations that those companies fraudulently assigned patients a higher Resource Utilization Group (RUG) level than necessary.

• April 10, 2017: Prestige Healthcare of Louisville, KY agreed to pay the United States $995,500 to resolve allegations related to unnecessary genetic testing of its nursing home patients. The United States alleged that in 2014 and 2015, Prestige provided Genomix LLC with insurance, medical information and access to patients in nursing homes for testing. Prestige failed to ensure that physician orders were obtained for the genetic testing prior to its being conducted. Physicians were not aware of and did not agree with the medical necessity of the testing and patients were not informed or provided opportunity to decline the testing.


Part D – Compounding Pharmacies

October 2018: Cooley Medical Equipment, Inc., an Eastern Kentucky medical equipment supplier headquartered in Prestonsburg, Kentucky, has agreed to pay $5,2 million to resolve allegations that it violated the False Claims Act by submitting false or fraudulent claims that misrepresented the ingredients used in certain compounded medical creams.

Cooley previously operated a pharmacy in Prestonsburg that in 2015 began making compounded medical creams. Compounding pharmacies, like Cooley’s, prepare customized medications for individual patients, usually by mixing ingredients in order to create a prescription cream. Cooley billed these prescriptions to government insurers, including Medicare, Kentucky Medicaid, and the Veterans Health Administration. Cooley misrepresented the nature of its Lidocaine and Prilocaine ingredients in its claims to federal insurers, falsely stating that Cooley’s compounded medical creams were made with cream-based Lidocaine and Prilocaine ingredients, instead of the bulk powder Cooley actually used.

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Limited License Practitioners

Podiatry

Providing “roster services” to an entire population of patients in a “captive audience” setting (Nursing Facilities, Assisted Living Facilities, other locations with high Medicare beneficiary populations)

Providing medically unnecessary routine foot care and billing as though debridement was performed

Chiropractic

Maintenance therapy—continuing to provide chiropractic services after the acute episode is over


Durable/Home Medical Equipment Suppliers

Prohibited telephone solicitation

“Overselling” or “upselling” braces, orthotics, or other equipment

Asking referring physicians to sign documents indicating the patient needs equipment or supplies when the physician has never assessed the patient

July 25, 2018, District of Columbia: The owner of a DME company pleaded guilty to devising and executing a scheme to submit false and fraudulent claims to Medicaid for durable medical equipment, including incontinence and wound care supplies, which she knew were not purchased or provided to Medicaid beneficiaries. All told, she submitted and caused the submission of at least $9.8 million in false and fraudulent claims to Medicaid.

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Durable/Home Medical Equipment Suppliers

February 19, 2019: The United States has intervened in a False Claims Act case alleging that Arriva Medical LLC (Arriva) and its parent Alere Inc. (Alere) submitted or caused false claims to the Medicare program for medically unnecessary glucometers and paid kickbacks to Medicare beneficiaries in the form of free glucometers and copayment waivers.

Arriva is a mail-order diabetic testing supply company based in Coral Springs, Florida, which, at one point, had operations in Antioch, Tennessee. The lawsuit alleges, Arriva, with the oversight and approval of Alere, offered “free upgrades” of glucometers to Medicare beneficiaries. Because Arriva required all new customers to receive a new meter, regardless of whether they already had a functioning meter, Arriva allegedly routinely submitted false claims to Medicare for medically unnecessary meters. Arriva also allegedly made no meaningful effort to collect copayments from beneficiaries for the meters or diabetic testing supplies subsequently purchased from Arriva for use in connection with the meters. The waiver of patient copays or provision of other benefits to induce patients to purchase a company’s items or services is prohibited by the Anti-Kickback Statute.

“


Inpatient Hospital

2018: Prime Healthcare Services, Inc. ("Prime") and Prime's Founder and Chief Executive Officer, Dr. Prem Reddy, have agreed to pay the United States $1.25 million to settle allegations that two Prime hospitals in Pennsylvania - Roxborough Memorial Hospital in Philadelphia and Lower Bucks Hospital in Bristol - knowingly submitted false claims to Medicare by engaging in the following conduct: (1) admitting patients to the hospital for overnight stays who required only less costly, outpatient care and (2) billing for more expensive patient diagnoses than the patients had (the latter practice known as "up-coding").

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Unnecessary Services

October 31, 2018: Dr. Anis Chalhoub of London, KY was sentenced to serve 42 months in federal prison for health care fraud. Dr. Chalhoub defrauded Medicare, Medicaid, and other insurers by implanting medically unnecessary pacemakers in his patients, and causing the unnecessary procedures and follow-up care to be billed to health insurance programs.

Between 2007 and 2011, Dr. Chalhoub implanted approximately 234 pacemakers in patients at St. Joseph London hospital. The evidence at trial showed that dozens of those patients’ pacemakers were medically unnecessary, under well-established national guidelines and Medicare coverage rules.

Patients testified at trial that Dr. Chalhoub pressured them into getting the procedures and told them misleading information about their health conditions. For instance, several patients recalled Dr. Chalhoub telling them that they might die without a pacemaker. Sinus node dysfunction, the diagnosis Dr. Chalhoub gave the patients, is a non-fatal condition.


All Physician Practices

Identity theft: theft or misuse of your billing numbers (PTAN, NPI, Medicaid number). Stolen numbers were used to falsify orders/ referrals and services provided directly to patients:

Owner of a DME company in Texas was sentenced to 99 months in Federal prison for routinely billing Medicaid for medically unnecessary supplies never delivered to beneficiaries. The owner used stolen beneficiary and physician medical identifiers to bill claims totaling more than $2 million.

A woman in Florida was sentenced to prison for using a New York physician’s medical identifiers from April 2004 through March 2007 to bill for services never rendered. She billed the services to a Medicare Part B carrier in New Jersey. The physician did not know the perpetrator, never saw any of the patients, and did not give permission to use his identity.

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Physicians are recruited as referring physicians for DME, Home Health, Lab. Specific problems include asking physicians to sign:

Referrals for patients they do not know

Certificates of Medical Necessity (CMNs) for patients they know but who do not need the service or supplies

CMNs even though their own documentation disputes medical need

CMNs for more than what patients actually need

Signing blank referral forms

• A physician was sentenced to prison for committing health care fraud. This physician accepted co-ownership of a health care clinic opened by a fraudster recruiting doctors. The physician never treated any of the patients but allowed the submission of claims in his name. He received patient files transported to his office, at a separate location, where he signed off on the services.



Ways to protect yourself, your practice, and your patients:

Keep enrollment information current

Monitor billing activity and ensure all staff members are following your compliance processes

Control unique medical identifiers

Physicians: learn about prospective employers (and employees) before you share your identifiers

Ensure your staff understands when and with whom they can share this information

Control prescription pads

Engage your patients; ensure they know they can request and receive their medical bills (particularly for Medicaid patients, who may not always receive a bill)

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Reporting Suspected Medicare Fraud


Reporting Potential Medicare Fraud

• Providers and patients may report online to the HHS Office of Inspector General

• https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx

• Providers may also call the Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477) or TTY: 1-800-377-4950

• Patients may report by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048

https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx







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What if My Claims are Audited by AdvanceMed?


If Claims from Your Office are Selected for Review AdvanceMed may contact you:

By phone to discuss current practice locations and other general information

By letter requesting medical records for a list of patients for specific dates of service

By a site visit (announced or unannounced)

If selected for review, be sure to:

Send requested medical records by specified date to specified address

Note: AdvanceMed’s document processing center is located in Virginia.

Include all requested portions of records requested: progress notes, PT notes, physician orders, etc.

Submit all information that supports the service billed

Cooperate with AdvanceMed team if there is an on-site audit

You may ask for identification

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If Claims from Your Office are Selected for Review • Substantiated allegations result in the potential for a variety of administrative actions, including:

Education regarding proper billing and/or documentation

Medicare Overpayment Determination

The first “educational” letter from the UPIC and give examples of errors found and total of the overpayment

A second “overpayment” letter will come from the MAC, CGS, and will contain information about how to submit the refund and also provides information on your appeal rights

Medicare Payment Suspension – with CMS approval

Medicare Revocation – with CMS approval

Referral to State Licensure Board

Referral to Quality Improvement Organization (QIO)

Referral to Law Enforcement (provider will not be made aware of this action)

• AdvanceMed monitors providers after the implementation of an administrative action to ensure compliance with Medicare policies and regulations

Summary

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Summary

• UPICs are the CMS contractors for Medicare and Medicaid anti-fraud activities

• Follow Medicare and Medicaid guidelines, as applicable, and standards of care when coding and submitting claims

• If selected for an audit, do not panic – simply cooperate and provide all requested information within the specified timeframes

• All citizens, providers, staff and contractors can work together to fight fraud and preserve the Medicare Trust Fund and Medicaid funds

11730 Plaza America Drive Reston, VA 20190 Main 703-707-6900 Fax 703-707-6901 [email protected]

www.nciinc.com

Thank you for your time and attention!

Documents

Fighting Medicare and Medicaid Fraud, Waste & Abuse · Medical LLC (Arriva) and its parent Alere Inc. (Alere) submitted or caused false claims to the Medicare program for medically