Fw: OIG Posts Report and Updates Enforcement Actions - 12/15

[Guest guest]

2 Idaho PT's found guilty of augmenting patient records

http://www.justice.gov/usao/id/news/2011/dec/pocatellophysicaltherapy12122011.ht\

ml

  W. , PT, MS

Grosse Pointe Woods, MI

Therapeutics

Michigan Board of Physical Therapy

dperrypt@...

" And in the end it's not the years in your life that count. It's the life in

your years. "

Abraham Lincoln

" A person who never made a mistake never tried anything new. "

Albert Einstein

----- Forwarded Message ----

To: dperrypt@...

Sent: Thu, December 15, 2011 9:40:30 AM

Subject: OIG Posts Report and Updates Enforcement Actions - 12/15

Good morning to all from Washington, DC.

Today OIG posts one report and updates enforcement actions. As always, you can

use the links provided to go directly to the new material.

_________________________________________________________________

Medicaid Managed Care: Fraud and Abuse Concerns Remain Despite Safeguards

(OEI-01-09-00550) http://go.usa.gov/NYw

We found that although managed care entities (MCE) and States are taking steps

to address fraud and abuse in managed care, they remain concerned about their

prevalence.

States have increasingly adopted managed care in response to Medicaid

expenditures, which have nearly doubled in the past decade. CMS requires MCEs to

meet specific program integrity requirements as a condition for receiving

payment. CMS also requires MCEs to disclose to States certain information, such

as ownership and control. States are directly responsible for monitoring MCE

operations. CMS’s Medicaid Integrity Group (MIG) conducts program integrity

reviews of States and MCEs. In 2000, CMS issued guidelines to States for

addressing fraud and abuse in Medicaid managed care. The guidelines identified

six areas of concern.

We surveyed a purposive sample of 46 MCEs and received responses from 45. We

conducted structured telephone interviews with the 13 States that contracted

with those MCEs. We also reviewed MIG’s files from its program integrity

reviews

of those 13 States and 46 MCEs.

All MCEs in our sample reported taking steps to meet the Federal program

integrity requirements. All 45 MCEs that responded to our questionnaire provided

fraud and abuse safeguard training to their staffs in 2010. Most also reported

offering such training to their providers. In 2009, 33 MCEs reported cases of

suspected fraud and abuse to their State Medicaid agencies, and 20 MCEs

recovered payments from providers that resulted from fraud and abuse.

The 13 States in our sample reported taking steps to oversee MCEs’ fraud and

abuse safeguards. All 13 States conduct desk reviews of MCEs’ compliance

plans,

and 11 States conduct onsite MCE reviews. All 13 States reported requiring that

MCEs disclose ownership and control information. Eleven States hold recurring

meetings with MCEs and often provide training.

The primary concern about Medicaid managed care fraud and abuse—shared by MCEs

and States—related to services billed but not received. The major concerns

identified in our review largely fall under only one of the six areas included

in CMS’s 2000 guidelines.

Managed care presents challenges in addressing fraud that differ from those in

fee-for-service Medicaid. As States increasingly use managed care to deliver

Medicaid services, implementing safeguards to protect against fraud and abuse

remains essential. We recommend that CMS require that State contracts with MCEs

include a method to verify with beneficiaries whether they received services

billed by providers. CMS could require States to implement one of several

options, such as for MCEs to send explanations of medical benefits to

beneficiaries. We also recommend that CMS update guidance to reflect concerns

expressed by MCEs and States. CMS could also share best practices and innovative

methods that States and MCEs have used to address fraud and abuse concerns and

strengthen program integrity oversight. CMS concurred with both recommendations.

__________________________________________________________________

December 14, 2011; U.S. Department of Justice

Three Patient Recruiters for Miami Home Health Companies Sentenced to Prison in

$25 Million Health Care Fraud Scheme

http://go.usa.gov/51i___________________________________________________________\

_______

December 14, 2011; U.S. Department of Justice

Owners of Houston Mental Health Company and Assisted Living Facility Indicted

for Alleged Roles in $90 Million Medicare Fraud Scheme

http://go.usa.gov/51i _________________________________________________________\

_________

December 14, 2011; U.S. Attorney; Eastern District of Pennsylvania

Philadelphia Doctor Charged With Running Pill Mill

http://go.usa.gov/51i _________________________________________________________\

_________

December 14, 2011; U.S. Attorney; District of Arizona News Release

Pain Management Doctor and Clinic Administrator Indicted On 130 Counts

http://go.usa.gov/51i _________________________________________________________\

_________

December 12, 2011

Co-owners of Pocatello Physical Therapy, P.A. Sentenced in Federal Court

http://go.usa.gov/51i

__________________________________________________________________

That’s all we have for now. If we can be of further assistance, please send an

Email to public.affairs@...

I hope your week is going well.

-- Marc Wolfson, Office of External Affairs

Follow us on Twitter: http://twitter.com/OIGatHHS

Inquiries? Contact us: Public.Affairs@...

Manage your OIG subscriptions: update your preferences or unsubscribe

Questions about this service? Support@...

________________________________

This email was sent to dperrypt@... using GovDelivery, on behalf of the U.S.

Dept. of Health & Human Services · 200 Independence Avenue SW · Washington DC

20201 · 1-

[Guest guest]

And a note to our cilleagues in facility based prqctices. The joint commission

now also looks for issues related to medicare conditions of participation which

has serious consequences that can become a legal issue for yourself and the

facility

Jim Dunleavy PT MS

Connected by DROID on Verizon Wireless

OIG Posts Report and Updates Enforcement Actions - 12/15

Good morning to all from Washington, DC.

Today OIG posts one report and updates enforcement actions. As always, you can

use the links provided to go directly to the new material.

_________________________________________________________________

Medicaid Managed Care: Fraud and Abuse Concerns Remain Despite Safeguards

(OEI-01-09-00550) http://go.usa.gov/NYw

We found that although managed care entities (MCE) and States are taking steps

to address fraud and abuse in managed care, they remain concerned about their

prevalence.

States have increasingly adopted managed care in response to Medicaid

expenditures, which have nearly doubled in the past decade. CMS requires MCEs to

meet specific program integrity requirements as a condition for receiving

payment. CMS also requires MCEs to disclose to States certain information, such

as ownership and control. States are directly responsible for monitoring MCE

operations. CMS’s Medicaid Integrity Group (MIG) conducts program integrity

reviews of States and MCEs. In 2000, CMS issued guidelines to States for

addressing fraud and abuse in Medicaid managed care. The guidelines identified

six areas of concern.

We surveyed a purposive sample of 46 MCEs and received responses from 45. We

conducted structured telephone interviews with the 13 States that contracted

with those MCEs. We also reviewed MIG’s files from its program integrity

reviews

of those 13 States and 46 MCEs.

All MCEs in our sample reported taking steps to meet the Federal program

integrity requirements. All 45 MCEs that responded to our questionnaire provided

fraud and abuse safeguard training to their staffs in 2010. Most also reported

offering such training to their providers. In 2009, 33 MCEs reported cases of

suspected fraud and abuse to their State Medicaid agencies, and 20 MCEs

recovered payments from providers that resulted from fraud and abuse.

The 13 States in our sample reported taking steps to oversee MCEs’ fraud and

abuse safeguards. All 13 States conduct desk reviews of MCEs’ compliance

plans,

and 11 States conduct onsite MCE reviews. All 13 States reported requiring that

MCEs disclose ownership and control information. Eleven States hold recurring

meetings with MCEs and often provide training.

The primary concern about Medicaid managed care fraud and abuse—shared by MCEs

and States—related to services billed but not received. The major concerns

identified in our review largely fall under only one of the six areas included

in CMS’s 2000 guidelines.

Managed care presents challenges in addressing fraud that differ from those in

fee-for-service Medicaid. As States increasingly use managed care to deliver

Medicaid services, implementing safeguards to protect against fraud and abuse

remains essential. We recommend that CMS require that State contracts with MCEs

include a method to verify with beneficiaries whether they received services

billed by providers. CMS could require States to implement one of several

options, such as for MCEs to send explanations of medical benefits to

beneficiaries. We also recommend that CMS update guidance to reflect concerns

expressed by MCEs and States. CMS could also share best practices and innovative

methods that States and MCEs have used to address fraud and abuse concerns and

strengthen program integrity oversight. CMS concurred with both recommendations.

__________________________________________________________________

December 14, 2011; U.S. Department of Justice

Three Patient Recruiters for Miami Home Health Companies Sentenced to Prison in

$25 Million Health Care Fraud Scheme

http://go.usa.gov/51i___________________________________________________________\

_______

December 14, 2011; U.S. Department of Justice

Owners of Houston Mental Health Company and Assisted Living Facility Indicted

for Alleged Roles in $90 Million Medicare Fraud Scheme

http://go.usa.gov/51i _________________________________________________________\

_________

December 14, 2011; U.S. Attorney; Eastern District of Pennsylvania

Philadelphia Doctor Charged With Running Pill Mill

http://go.usa.gov/51i _________________________________________________________\

_________

December 14, 2011; U.S. Attorney; District of Arizona News Release

Pain Management Doctor and Clinic Administrator Indicted On 130 Counts

http://go.usa.gov/51i _________________________________________________________\

_________

December 12, 2011

Co-owners of Pocatello Physical Therapy, P.A. Sentenced in Federal Court

http://go.usa.gov/51i

__________________________________________________________________

That’s all we have for now. If we can be of further assistance, please send an

Email to public.affairs@...

I hope your week is going well.

-- Marc Wolfson, Office of External Affairs

Follow us on Twitter: http://twitter.com/OIGatHHS

Inquiries? Contact us: Public.Affairs@...

Manage your OIG subscriptions: update your preferences or unsubscribe

Questions about this service? Support@...

________________________________

This email was sent to dperrypt@... using GovDelivery, on behalf of the U.S.

Dept. of Health & Human Services · 200 Independence Avenue SW · Washington DC

20201 · 1-

[Guest guest]

And a note to our cilleagues in facility based prqctices. The joint commission

now also looks for issues related to medicare conditions of participation which

has serious consequences that can become a legal issue for yourself and the

facility

Jim Dunleavy PT MS

Connected by DROID on Verizon Wireless

OIG Posts Report and Updates Enforcement Actions - 12/15

Good morning to all from Washington, DC.

Today OIG posts one report and updates enforcement actions. As always, you can

use the links provided to go directly to the new material.

_________________________________________________________________

Medicaid Managed Care: Fraud and Abuse Concerns Remain Despite Safeguards

(OEI-01-09-00550) http://go.usa.gov/NYw

We found that although managed care entities (MCE) and States are taking steps

to address fraud and abuse in managed care, they remain concerned about their

prevalence.

States have increasingly adopted managed care in response to Medicaid

expenditures, which have nearly doubled in the past decade. CMS requires MCEs to

meet specific program integrity requirements as a condition for receiving

payment. CMS also requires MCEs to disclose to States certain information, such

as ownership and control. States are directly responsible for monitoring MCE

operations. CMS’s Medicaid Integrity Group (MIG) conducts program integrity

reviews of States and MCEs. In 2000, CMS issued guidelines to States for

addressing fraud and abuse in Medicaid managed care. The guidelines identified

six areas of concern.

We surveyed a purposive sample of 46 MCEs and received responses from 45. We

conducted structured telephone interviews with the 13 States that contracted

with those MCEs. We also reviewed MIG’s files from its program integrity

reviews

of those 13 States and 46 MCEs.

All MCEs in our sample reported taking steps to meet the Federal program

integrity requirements. All 45 MCEs that responded to our questionnaire provided

fraud and abuse safeguard training to their staffs in 2010. Most also reported

offering such training to their providers. In 2009, 33 MCEs reported cases of

suspected fraud and abuse to their State Medicaid agencies, and 20 MCEs

recovered payments from providers that resulted from fraud and abuse.

The 13 States in our sample reported taking steps to oversee MCEs’ fraud and

abuse safeguards. All 13 States conduct desk reviews of MCEs’ compliance

plans,

and 11 States conduct onsite MCE reviews. All 13 States reported requiring that

MCEs disclose ownership and control information. Eleven States hold recurring

meetings with MCEs and often provide training.

The primary concern about Medicaid managed care fraud and abuse—shared by MCEs

and States—related to services billed but not received. The major concerns

identified in our review largely fall under only one of the six areas included

in CMS’s 2000 guidelines.

Managed care presents challenges in addressing fraud that differ from those in

fee-for-service Medicaid. As States increasingly use managed care to deliver

Medicaid services, implementing safeguards to protect against fraud and abuse

remains essential. We recommend that CMS require that State contracts with MCEs

include a method to verify with beneficiaries whether they received services

billed by providers. CMS could require States to implement one of several

options, such as for MCEs to send explanations of medical benefits to

beneficiaries. We also recommend that CMS update guidance to reflect concerns

expressed by MCEs and States. CMS could also share best practices and innovative

methods that States and MCEs have used to address fraud and abuse concerns and

strengthen program integrity oversight. CMS concurred with both recommendations.

__________________________________________________________________

December 14, 2011; U.S. Department of Justice

Three Patient Recruiters for Miami Home Health Companies Sentenced to Prison in

$25 Million Health Care Fraud Scheme

http://go.usa.gov/51i___________________________________________________________\

_______

December 14, 2011; U.S. Department of Justice

Owners of Houston Mental Health Company and Assisted Living Facility Indicted

for Alleged Roles in $90 Million Medicare Fraud Scheme

http://go.usa.gov/51i _________________________________________________________\

_________

December 14, 2011; U.S. Attorney; Eastern District of Pennsylvania

Philadelphia Doctor Charged With Running Pill Mill

http://go.usa.gov/51i _________________________________________________________\

_________

December 14, 2011; U.S. Attorney; District of Arizona News Release

Pain Management Doctor and Clinic Administrator Indicted On 130 Counts

http://go.usa.gov/51i _________________________________________________________\

_________

December 12, 2011

Co-owners of Pocatello Physical Therapy, P.A. Sentenced in Federal Court

http://go.usa.gov/51i

__________________________________________________________________

That’s all we have for now. If we can be of further assistance, please send an

Email to public.affairs@...

I hope your week is going well.

-- Marc Wolfson, Office of External Affairs

Follow us on Twitter: http://twitter.com/OIGatHHS

Inquiries? Contact us: Public.Affairs@...

Manage your OIG subscriptions: update your preferences or unsubscribe

Questions about this service? Support@...

________________________________

This email was sent to dperrypt@... using GovDelivery, on behalf of the U.S.

Dept. of Health & Human Services · 200 Independence Avenue SW · Washington DC

20201 · 1-