Guest guest Posted December 6, 2011 Report Share Posted December 6, 2011 Thanks for posting . The thing that seems to be the common denominator on all of the scams is storefront locations with no real patients ever seen. The second I hear of a big fraud, you can almost bet that's the meat of it. Seems to me like that should be the easiest waste to spot. Why don't patients call in when they get EOBs for work never done? Thanks for all you do for us. Doug New on PTManager Blog [image: Posterous Spaces] [image: Your Daily Update] December 6th, 2011 Home health care firms breaking rules, raking in Medicare dollars - Houston Chronicle<http://ptmanagerblog.com/home-health-care-firms-breaking-rules-raking<\ http://ptmanagerblog.com/home-health-care-firms-breaking-rules-raking>> Posted about 23 hours ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv<http://posterous.com/users/1l1oCkDWEWjv\ >> to PTManager<http://ptmanagerblog.com<http://ptmanagerblog.com/>> [image: Like this post]<http://posterous.com/likes/create?post_id=84090448<http://posterous.com/li\ kes/create?post_id=84090448>> Home health care firms breaking rules, raking in Medicare dollars TERRI LANGFOR, HOUSTON CHRONICLE Copyright 2011 HOUSTON CHRONICLE. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.<http://www.chron.com/news/houston-texas/article/Home-health-care-\ firms-breaking-rules-raking-in-2342534.php#license-4edcc84543af4<http://www.chro\ n.com/news/houston-texas/article/Home-health-care-firms-breaking-rules-raking-in\ -2342534.php#license-4edcc84543af4>> By TERRI LANGFORD, HOUSTON CHRONICLE Updated 10:11 p.m., Saturday, December 3, 2011 $1.25 billion: Medicare money paid to Houston area agencies over four years. $334 million: Amount paid in 2010. 468: Number of companies in Houston region. 129: Number of companies paid at least $1 million in 2010. 289: Number of companies receiving at least $1 million between 2007 and 2010. Source: Chronicle analysis of Centers for Medicare and Medicaid Services data American taxpayers spend tens of millions of dollars on Medicare (Page 1 of 2) The nation's Medicare<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Medicare%22>program<http://www.ch\ ron.com/?controllerName=search & action=search & channel=news%2Fhouston-texas & search\ =1 & inlineLink=1 & query=%22Medicare%22>program> has dished out $1.25 billion for home-based health care in Houston over four years - and yet nearly every agency that provides nurses, therapists and drugs for the elderly and disabled has violated state and federal standards, a Houston Chronicle<http://www.chron.com/?controllerName=search & action=search & channel=news\ %2Fhouston-texas & search=1 & inlineLink=1 & query=%22Houston+Chronicle%22>investigati\ on<http://www.chron.com/?controllerName=search & action=search & channel=news%2Fhous\ ton-texas & search=1 & inlineLink=1 & query=%22Houston+Chronicle%22>investigation> has found. Still, little stops the flow of taxpayer dollars to the nearly 470 companies based in America's fourth largest city. Dubbed " deficiencies " by the Texas Department<http://www.chron.com/?controllerName=search & action=search & channel=new\ s%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Texas+Department%22>of<http://w\ ww.chron.com/?controllerName=search & action=search & channel=news%2Fhouston-texas & s\ earch=1 & inlineLink=1 & query=%22Texas+Department%22>of> Aging and Disability Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Aging+and+Disability+Services%22<\ http://www.chron.com/?controllerName=search & action=search & channel=news%2Fhouston\ -texas & search=1 & inlineLink=1 & query=%22Aging+and+Disability+Services%22>>, they include violations like failure to make sure drugs and treatments are administered properly and failure to report abuse of a patient. Federal authorities say not only are companies falling short on certain standards of care, some also are bastions for potential fraud - its victims patients and taxpayers. Though federal authorities declined to provide details, citing ongoing investigations, Assistant U.S. Attorney Justo Mendez<http://www.chron.com/?controllerName=search & action=search & channel=news%2F\ houston-texas & search=1 & inlineLink=1 & query=%22Justo+Mendez%22>told<http://www.chr\ on.com/?controllerName=search & action=search & channel=news%2Fhouston-texas & search=\ 1 & inlineLink=1 & query=%22Justo+Mendez%22>told> the Chronicle that some of the company billings in Houston are the result of " fraudsters " who " bill for services not rendered. " Earlier this year, Houston's Craig O'Connor<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Craig+O%27Connor%22>was<http://ww\ w.chron.com/?controllerName=search & action=search & channel=news%2Fhouston-texas & se\ arch=1 & inlineLink=1 & query=%22Craig+O%27Connor%22>was> witness to the wiles of the industry. His elderly mother, suffering from a poorly healed wound on her foot, was sent home from the hospital with a recommendation to use a home health care agency to help her recovery. Instead, he says his mother's convalescence was turned upside down as workers from the recommended company made a beeline to his mother's door. " This was my first experience with Medicare, and I quickly became alarmed about all the doctors and health aides who were practically falling all over themselves to schedule house calls to see my mother, " O'Connor recalled. One of the " doctors " who showed up wasn't even really a doctor, he said. Federal auditors repeatedly have noted the exploding and profitable growth of home health care in the Lone Star State, where Medicare spending has blown up to three times the national growth rate. The Chronicle's examination of payment records showed that even in the tiny town of Edinburg in South Texas, 27 home health care agencies have received $331 million over the last four years. Two months ago, a Chronicle investigation of the private ambulance business found millions in Medicare dollars spent on questionable transports of able-bodied patients to mental health clinics. *Booming business* Houston's County leads the nation in the number of nonemergency ambulances, companies and Medicare billings with more than $62 million coming to some 400 companies in 2009 alone. And yet, the home health care industry is even larger - and richer: $384 million was paid to 468 Houston companies in 2010. Like private ambulances, no one state agency is charged with determining how much money is too much, or how many companies are too many. And Medicare's direct contact with the companies that bill the mammoth insurance agency for the elderly and disabled is minimal. The Centers for Medicare and Medicaid Services, or CMS, delegates nearly all of its authority to contractors, a mix of private companies and state agencies. Those contractors, not the federal agency, decide what companies qualify for Medicare and pay the patients' bills. *'Termination track'* In Texas, it's the state Department of Aging and Disability<http://www.chron.com/?controllerName=search & action=search & channel=new\ s%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Department+of+Aging+and+Disabil\ ity%22>Services<http://www.chron.com/?controllerName=search & action=search & channe\ l=news%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Department+of+Aging+and+Di\ sability%22>Services>, or DADS, that does the licensing, inspecting and investigating of home health agencies - a chore it is contracted to do for Medicare as well. If the agency finds federal violations that endanger a patient's health, the report is sent to CMS and a " termination track " clock begins. The company has 90 days to correct the problems, with DADS in charge of checking back. Through all of this, however, no one from the $760-billion CMS ever sets an eyeball on a home health agency in Houston, where 289 companies have collected $1 million or more from 2007 through 2010. Last year, 129 companies hit the $1 million Medicare mark. When asked exactly how many agencies in Texas with federal violations end up on Medicare's " termination " track, CMS' Dallas spokesman Bob Moos<http://www.chron.com/?controllerName=search & action=search & channel=news%2Fho\ uston-texas & search=1 & inlineLink=1 & query=%22Bob+Moos%22>referred<http://www.chron\ ..com/?controllerName=search & action=search & channel=news%2Fhouston-texas & search=1 & \ inlineLink=1 & query=%22Bob+Moos%22>referred> the question back to Texas authorities. " We're not aware of any Texas home health care providers on a . termination track at the moment, but, frankly, DADS will have a better handle on this, since it's the one that actually does the inspections, " Moos said. Home health care agencies say they're being overly scrutinized because of fraud in the industry, with nearly every agency getting dinged for infractions that aren't that serious. " I respect the home health industry's position on this, but we're not going to let up on them, " said DADS Commissioner Chris Traylor<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Chris+Traylor%22<http://www.chron.\ com/?controllerName=search & action=search & channel=news%2Fhouston-texas & search=1 & i\ nlineLink=1 & query=%22Chris+Traylor%22>>. " Our job is to hold them accountable for any violations we find, and that won't be changing. " The hundreds of deficiencies run the gamut from the bureaucratic, like missing paperwork, to the problematic: not reporting within 24 hours knowledge of an act of abuse, neglect or exploitation by a worker; failing to make sure a patient's care plan is reviewed by doctors; nurses or therapy supervisors not making home visits when required; not checking properly for Medicare eligibility; and lacking written plans to control infection and disease. But if no agency is about to be terminated and risk losing tens of thousands, if not millions of dollars in Medicare money, why have an inspection system? " Our top priority is the health and safety of the clients, " said DADS spokeswoman Cecilia Fedorov<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Cecilia+Fedorov%22<http://www.chro\ n.com/?controllerName=search & action=search & channel=news%2Fhouston-texas & search=1\ & inlineLink=1 & query=%22Cecilia+Fedorov%22>>. " Our investigations focus on the quality of care provided and when we find that an agency is not in compliance with regulations, we require timely and appropriate corrections. " Last month, the U.S. Department of Health and Human Services' Office of Inspector General<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Office+of+Inspector+General%22>rep\ orted<http://www.chron.com/?controllerName=search & action=search & channel=news%2Fh\ ouston-texas & search=1 & inlineLink=1 & query=%22Office+of+Inspector+General%22>repor\ ted> that contractors charged with detecting fraud have had a series of problems that " affected their ability to identify potential fraud and abuse " and track the collection of overpayments. *Bad coordination?* " The government has enough information that they should be able to find this stuff. They ought to go look, " said Hammon<http://www.chron.com/?controllerName=search & action=search & channel=news%2F\ houston-texas & search=1 & inlineLink=1 & query=%22+Hammon%22<http://www.chron.c\ om/?controllerName=search & action=search & channel=news%2Fhouston-texas & search=1 & in\ lineLink=1 & query=%22+Hammon%22>>, director of clinical practice and regulatory affairs for the Texas Association of Home Care & Hospice. " I think the big problem I see is how the various government agencies coordinate. Each one says 'That's not what I do' or 'I'm not funded.' " Some health care agencies counter that they're made scapegoats by the inspections as both state and federal agencies are pressured to do something about the nation's soaring Medicare bills. *'I go by the rules'* Edna Lewin, administrator of The Trend Health Care Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22The+Trend+Health+Care+Services%22\ <http://www.chron.com/?controllerName=search & action=search & channel=news%2Fhousto\ n-texas & search=1 & inlineLink=1 & query=%22The+Trend+Health+Care+Services%22>>, says violations do not mean home health agencies or their workers are not safe. The 32 " deficiencies " her company received in 2009 - the most by one company in Houston - were all corrected. " You need to know the story, " she said. " I live above-board. If I didn't, I wouldn't be in business. " Dorothy , a registered nurse who created her Lanoitan Home Health Care of Texas in 1978, was cited for 21 deficiencies last year, all of which she says were corrected immediately. " If you look at my record, it's superb, " she said. " I think I'm getting the flak because there's so much fraud in home health care. I refuse to be a part of it. I'm old school. I go by the rules. " In 2009, the General Accountability Office reported Medicare's spending on home health care totaled $12.9 billion in 2006, up 44 percent in 2002. It also zeroed in on several problems, some in Houston, including home health care agencies' propensity to overstate a patients' condition in order to get Medicare money. Nearly 700 patients deemed most severe " were served by potentially fraudulent (home health care), " the audit stated. Federal officials in Houston also are investigating kickback schemes and billing for " services not rendered " but could not comment on specifics. " Law enforcement's efforts alone will not stop this fraud, " said Elvis McBride, who supervises the FBI's Health Care Fraud Task Force in Houston. " It takes CMS or Medicare to put edits in place to prevent certain types of payouts. It takes education (for Medicare patients). " *Billing doubles* Even before Houston's explosive growth in home health care, federal auditors noted that not only had the number of people getting Medicare benefits doubled, but so did the number of times agencies billed for a visit to a patient: from 36 times to 73. " I have a problem with the government not watching who is billing what, " said Anita Bradberry, executive director of the Texas Association of Home Care & Hospice. " It's not that home health is bad. Home health is the solution to a lot of our health care problems. " via chron.com<http://www.chron.com/news/houston-texas/article/Home-health-care-firms\ -breaking-rules-raking-in-2342534.php<http://www.chron.com/news/houston-texas/ar\ ticle/Home-health-care-firms-breaking-rules-raking-in-2342534.php>> [image: App] On the go? *Download Posterous Spaces* for your phone <http://posterous.com/mobile<http://posterous.com/mobile>> Sent by Posterous. Is this spam? Report it here<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions<ht\ tp://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions>>. Manage or unsubscribe email subscriptions<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscri\ ptions<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions>\ > Other questions? We'd love to help. <http://help.posterous.com<http://help.posterous.com/>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 6, 2011 Report Share Posted December 6, 2011 Well, I hope all those that have repeatedly claimed that fraud is not rampant or a huge problem and those that repeatedly call for less regulations wihtout understanding WHY there are so many Medicare regulations in the first place are reading this and changing there tune. How many more of these studies do we have to have before you understand how bad healthcare fraud is and the extent of the regulatory burden that is placed on us because of it? M Howell,. PT, MPT IPTA Payment Specialist Meridian, Idaho thowell@...> [image: Posterous Spaces] > [image: Your Daily Update] December 6th, 2011 Home health care > firms breaking rules, raking in Medicare dollars - Houston > Chronicle<http://ptmanagerblog.com/home-health-care-firms-breaking-rules-raking> > > Posted about 23 hours ago by [image: _portrait_thumb] > Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to > PTManager<http://ptmanagerblog.com> > [image: Like this > post]<http://posterous.com/likes/create?post_id=84090448> > > Home health care firms breaking rules, raking in Medicare dollars > TERRI LANGFOR, HOUSTON CHRONICLE Copyright 2011 HOUSTON CHRONICLE. All > rights reserved. This material may not be published, broadcast, > rewritten or > redistributed.<http://www.chron.com/news/houston-texas/article/Home-health-care-\ firms-breaking-rules-raking-in-2342534.php#license-4edcc84543af4> > By TERRI LANGFORD, HOUSTON CHRONICLE Updated 10:11 p.m., Saturday, > December 3, 2011 > > $1.25 billion: Medicare money paid to Houston area agencies over four > years. > > $334 million: Amount paid in 2010. > > 468: Number of companies in Houston region. > > 129: Number of companies paid at least $1 million in 2010. > > 289: Number of companies receiving at least $1 million between 2007 and > 2010. > > Source: Chronicle analysis of Centers for Medicare and Medicaid Services > data > American taxpayers spend tens of millions of dollars on Medicare > (Page 1 of 2) > > The nation's > Medicare<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Medicare%22>program > has dished out $1.25 billion for home-based health care in Houston over > four years - and yet nearly every agency that provides nurses, > therapists and drugs for the elderly and disabled has violated state and > federal standards, a Houston > Chronicle<http://www.chron.com/?controllerName=search & action=search & channel=news\ %2Fhouston-texas & search=1 & inlineLink=1 & query=%22Houston+Chronicle%22>investigati\ on > has found. > > Still, little stops the flow of taxpayer dollars to the nearly 470 > companies based in America's fourth largest city. > > Dubbed " deficiencies " by the Texas > Department<http://www.chron.com/?controllerName=search & action=search & channel=new\ s%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Texas+Department%22>of > Aging > and Disability > Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Aging+and+Disability+Services%22>\ , > they include violations like failure to make sure drugs and treatments > are administered properly and failure to report abuse of a patient. > > Federal authorities say not only are companies falling short on certain > standards of care, some also are bastions for potential fraud - its > victims patients and taxpayers. > > Though federal authorities declined to provide details, citing ongoing > investigations, Assistant U.S. Attorney Justo > Mendez<http://www.chron.com/?controllerName=search & action=search & channel=news%2F\ houston-texas & search=1 & inlineLink=1 & query=%22Justo+Mendez%22>told > the Chronicle that some of the company billings in Houston are the > result of " fraudsters " who " bill for services not rendered. " > > Earlier this year, Houston's Craig > O'Connor<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Craig+O%27Connor%22>was > witness to the wiles of the industry. > > His elderly mother, suffering from a poorly healed wound on her foot, > was sent home from the hospital with a recommendation to use a home > health care agency to help her recovery. Instead, he says his mother's > convalescence was turned upside down as workers from the recommended > company made a beeline to his mother's door. > > " This was my first experience with Medicare, and I quickly became > alarmed about all the doctors and health aides who were practically > falling all over themselves to schedule house calls to see my mother, " > O'Connor recalled. > > One of the " doctors " who showed up wasn't even really a doctor, he said. > > Federal auditors repeatedly have noted the exploding and profitable > growth of home health care in the Lone Star State, where Medicare > spending has blown up to three times the national growth rate. > > The Chronicle's examination of payment records showed that even in the > tiny town of Edinburg in South Texas, 27 home health care agencies have > received $331 million over the last four years. > > Two months ago, a Chronicle investigation of the private ambulance > business found millions in Medicare dollars spent on questionable > transports of able-bodied patients to mental health clinics. > > *Booming business* > > Houston's County leads the nation in the number of nonemergency > ambulances, companies and Medicare billings with more than $62 million > coming to some 400 companies in 2009 alone. > > And yet, the home health care industry is even larger - and richer: $384 > million was paid to 468 Houston companies in 2010. > > Like private ambulances, no one state agency is charged with determining > how much money is too much, or how many companies are too many. And > Medicare's direct contact with the companies that bill the mammoth > insurance agency for the elderly and disabled is minimal. > > The Centers for Medicare and Medicaid Services, or CMS, delegates nearly > all of its authority to contractors, a mix of private companies and > state agencies. Those contractors, not the federal agency, decide what > companies qualify for Medicare and pay the patients' bills. > > *'Termination track'* > > In Texas, it's the state Department of Aging and > Disability<http://www.chron.com/?controllerName=search & action=search & channel=new\ s%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Department+of+Aging+and+Disabil\ ity%22>Services, > or DADS, that does the licensing, inspecting and investigating of > home health agencies - a chore it is contracted to do for Medicare as > well. > > If the agency finds federal violations that endanger a patient's health, > the report is sent to CMS and a " termination track " clock begins. The > company has 90 days to correct the problems, with DADS in charge of > checking back. > > Through all of this, however, no one from the $760-billion CMS ever sets > an eyeball on a home health agency in Houston, where 289 companies have > collected $1 million or more from 2007 through 2010. > > Last year, 129 companies hit the $1 million Medicare mark. > > When asked exactly how many agencies in Texas with federal violations > end up on Medicare's " termination " track, CMS' Dallas spokesman Bob > Moos<http://www.chron.com/?controllerName=search & action=search & channel=news%2Fho\ uston-texas & search=1 & inlineLink=1 & query=%22Bob+Moos%22>referred > the question back to Texas authorities. > > " We're not aware of any Texas home health care providers on a … > termination track at the moment, but, frankly, DADS will have a better > handle on this, since it's the one that actually does the inspections, " > Moos said. > > Home health care agencies say they're being overly scrutinized because > of fraud in the industry, with nearly every agency getting dinged for > infractions that aren't that serious. > > " I respect the home health industry's position on this, but we're not > going to let up on them, " said DADS Commissioner Chris > Traylor<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Chris+Traylor%22>. > " Our job is to hold them accountable for any violations we find, and > that won't be changing. " > > The hundreds of deficiencies run the gamut from the bureaucratic, like > missing paperwork, to the problematic: not reporting within 24 hours > knowledge of an act of abuse, neglect or exploitation by a worker; > failing to make sure a patient's care plan is reviewed by doctors; > nurses or therapy supervisors not making home visits when required; not > checking properly for Medicare eligibility; and lacking written plans to > control infection and disease. > > But if no agency is about to be terminated and risk losing tens of > thousands, if not millions of dollars in Medicare money, why have an > inspection system? > > " Our top priority is the health and safety of the clients, " said DADS > spokeswoman Cecilia > Fedorov<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Cecilia+Fedorov%22>. > " Our investigations focus on the quality of care provided and when we > find that an agency is not in compliance with regulations, we require > timely and appropriate corrections. " > > Last month, the U.S. Department of Health and Human Services' Office of > Inspector > General<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Office+of+Inspector+General%22>rep\ orted > that contractors charged with detecting fraud have had a series of > problems that " affected their ability to identify potential fraud and > abuse " and track the collection of overpayments. > > *Bad coordination?* > > " The government has enough information that they should be able to find > this stuff. They ought to go look, " said > Hammon<http://www.chron.com/?controllerName=search & action=search & channel=news%2F\ houston-texas & search=1 & inlineLink=1 & query=%22+Hammon%22>, > director of clinical practice and regulatory affairs for the Texas > Association of Home Care & Hospice. " I think the big problem I see is > how the various government agencies coordinate. Each one says 'That's > not what I do' or 'I'm not funded.' " > > Some health care agencies counter that they're made scapegoats by the > inspections as both state and federal agencies are pressured to do > something about the nation's soaring Medicare bills. > > *'I go by the rules'* > > Edna Lewin, administrator of The Trend Health Care > Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22The+Trend+Health+Care+Services%22\ >, > says violations do not mean home health agencies or their workers are > not safe. > > The 32 " deficiencies " her company received in 2009 - the most by one > company in Houston - were all corrected. > > " You need to know the story, " she said. " I live above-board. If I > didn't, I wouldn't be in business. " > > Dorothy , a registered nurse who created her Lanoitan Home Health > Care of Texas in 1978, was cited for 21 deficiencies last year, all of > which she says were corrected immediately. > > " If you look at my record, it's superb, " she said. " I think I'm getting > the flak because there's so much fraud in home health care. I refuse to > be a part of it. I'm old school. I go by the rules. " > > In 2009, the General Accountability Office reported Medicare's spending > on home health care totaled $12.9 billion in 2006, up 44 percent in > 2002. > > It also zeroed in on several problems, some in Houston, including home > health care agencies' propensity to overstate a patients' condition in > order to get Medicare money. Nearly 700 patients deemed most severe > " were served by potentially fraudulent (home health care), " the audit > stated. > > Federal officials in Houston also are investigating kickback schemes and > billing for " services not rendered " but could not comment on specifics. > > " Law enforcement's efforts alone will not stop this fraud, " said Elvis > McBride, who supervises the FBI's Health Care Fraud Task Force in > Houston. " It takes CMS or Medicare to put edits in place to prevent > certain types of payouts. It takes education (for Medicare patients). " > > *Billing doubles* > > Even before Houston's explosive growth in home health care, federal > auditors noted that not only had the number of people getting Medicare > benefits doubled, but so did the number of times agencies billed for a > visit to a patient: from 36 times to 73. > > " I have a problem with the government not watching who is billing what, " > said Anita Bradberry, executive director of the Texas Association of > Home Care & Hospice. " It's not that home health is bad. Home health is > the solution to a lot of our health care problems. " > > via > chron.com<http://www.chron.com/news/houston-texas/article/Home-health-care-firms\ -breaking-rules-raking-in-2342534.php> > > > [image: App] On the go? > *Download Posterous Spaces* for your phone > <http://posterous.com/mobile> > Sent by Posterous. Is this spam? Report it > here<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions>. > Manage or unsubscribe email > subscriptions<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscri\ ptions> > Other > questions? We’d love to help. <http://help.posterous.com> > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 6, 2011 Report Share Posted December 6, 2011 Well, I hope all those that have repeatedly claimed that fraud is not rampant or a huge problem and those that repeatedly call for less regulations wihtout understanding WHY there are so many Medicare regulations in the first place are reading this and changing there tune. How many more of these studies do we have to have before you understand how bad healthcare fraud is and the extent of the regulatory burden that is placed on us because of it? M Howell,. PT, MPT IPTA Payment Specialist Meridian, Idaho thowell@...> [image: Posterous Spaces] > [image: Your Daily Update] December 6th, 2011 Home health care > firms breaking rules, raking in Medicare dollars - Houston > Chronicle<http://ptmanagerblog.com/home-health-care-firms-breaking-rules-raking> > > Posted about 23 hours ago by [image: _portrait_thumb] > Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to > PTManager<http://ptmanagerblog.com> > [image: Like this > post]<http://posterous.com/likes/create?post_id=84090448> > > Home health care firms breaking rules, raking in Medicare dollars > TERRI LANGFOR, HOUSTON CHRONICLE Copyright 2011 HOUSTON CHRONICLE. All > rights reserved. This material may not be published, broadcast, > rewritten or > redistributed.<http://www.chron.com/news/houston-texas/article/Home-health-care-\ firms-breaking-rules-raking-in-2342534.php#license-4edcc84543af4> > By TERRI LANGFORD, HOUSTON CHRONICLE Updated 10:11 p.m., Saturday, > December 3, 2011 > > $1.25 billion: Medicare money paid to Houston area agencies over four > years. > > $334 million: Amount paid in 2010. > > 468: Number of companies in Houston region. > > 129: Number of companies paid at least $1 million in 2010. > > 289: Number of companies receiving at least $1 million between 2007 and > 2010. > > Source: Chronicle analysis of Centers for Medicare and Medicaid Services > data > American taxpayers spend tens of millions of dollars on Medicare > (Page 1 of 2) > > The nation's > Medicare<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Medicare%22>program > has dished out $1.25 billion for home-based health care in Houston over > four years - and yet nearly every agency that provides nurses, > therapists and drugs for the elderly and disabled has violated state and > federal standards, a Houston > Chronicle<http://www.chron.com/?controllerName=search & action=search & channel=news\ %2Fhouston-texas & search=1 & inlineLink=1 & query=%22Houston+Chronicle%22>investigati\ on > has found. > > Still, little stops the flow of taxpayer dollars to the nearly 470 > companies based in America's fourth largest city. > > Dubbed " deficiencies " by the Texas > Department<http://www.chron.com/?controllerName=search & action=search & channel=new\ s%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Texas+Department%22>of > Aging > and Disability > Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Aging+and+Disability+Services%22>\ , > they include violations like failure to make sure drugs and treatments > are administered properly and failure to report abuse of a patient. > > Federal authorities say not only are companies falling short on certain > standards of care, some also are bastions for potential fraud - its > victims patients and taxpayers. > > Though federal authorities declined to provide details, citing ongoing > investigations, Assistant U.S. Attorney Justo > Mendez<http://www.chron.com/?controllerName=search & action=search & channel=news%2F\ houston-texas & search=1 & inlineLink=1 & query=%22Justo+Mendez%22>told > the Chronicle that some of the company billings in Houston are the > result of " fraudsters " who " bill for services not rendered. " > > Earlier this year, Houston's Craig > O'Connor<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Craig+O%27Connor%22>was > witness to the wiles of the industry. > > His elderly mother, suffering from a poorly healed wound on her foot, > was sent home from the hospital with a recommendation to use a home > health care agency to help her recovery. Instead, he says his mother's > convalescence was turned upside down as workers from the recommended > company made a beeline to his mother's door. > > " This was my first experience with Medicare, and I quickly became > alarmed about all the doctors and health aides who were practically > falling all over themselves to schedule house calls to see my mother, " > O'Connor recalled. > > One of the " doctors " who showed up wasn't even really a doctor, he said. > > Federal auditors repeatedly have noted the exploding and profitable > growth of home health care in the Lone Star State, where Medicare > spending has blown up to three times the national growth rate. > > The Chronicle's examination of payment records showed that even in the > tiny town of Edinburg in South Texas, 27 home health care agencies have > received $331 million over the last four years. > > Two months ago, a Chronicle investigation of the private ambulance > business found millions in Medicare dollars spent on questionable > transports of able-bodied patients to mental health clinics. > > *Booming business* > > Houston's County leads the nation in the number of nonemergency > ambulances, companies and Medicare billings with more than $62 million > coming to some 400 companies in 2009 alone. > > And yet, the home health care industry is even larger - and richer: $384 > million was paid to 468 Houston companies in 2010. > > Like private ambulances, no one state agency is charged with determining > how much money is too much, or how many companies are too many. And > Medicare's direct contact with the companies that bill the mammoth > insurance agency for the elderly and disabled is minimal. > > The Centers for Medicare and Medicaid Services, or CMS, delegates nearly > all of its authority to contractors, a mix of private companies and > state agencies. Those contractors, not the federal agency, decide what > companies qualify for Medicare and pay the patients' bills. > > *'Termination track'* > > In Texas, it's the state Department of Aging and > Disability<http://www.chron.com/?controllerName=search & action=search & channel=new\ s%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Department+of+Aging+and+Disabil\ ity%22>Services, > or DADS, that does the licensing, inspecting and investigating of > home health agencies - a chore it is contracted to do for Medicare as > well. > > If the agency finds federal violations that endanger a patient's health, > the report is sent to CMS and a " termination track " clock begins. The > company has 90 days to correct the problems, with DADS in charge of > checking back. > > Through all of this, however, no one from the $760-billion CMS ever sets > an eyeball on a home health agency in Houston, where 289 companies have > collected $1 million or more from 2007 through 2010. > > Last year, 129 companies hit the $1 million Medicare mark. > > When asked exactly how many agencies in Texas with federal violations > end up on Medicare's " termination " track, CMS' Dallas spokesman Bob > Moos<http://www.chron.com/?controllerName=search & action=search & channel=news%2Fho\ uston-texas & search=1 & inlineLink=1 & query=%22Bob+Moos%22>referred > the question back to Texas authorities. > > " We're not aware of any Texas home health care providers on a … > termination track at the moment, but, frankly, DADS will have a better > handle on this, since it's the one that actually does the inspections, " > Moos said. > > Home health care agencies say they're being overly scrutinized because > of fraud in the industry, with nearly every agency getting dinged for > infractions that aren't that serious. > > " I respect the home health industry's position on this, but we're not > going to let up on them, " said DADS Commissioner Chris > Traylor<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Chris+Traylor%22>. > " Our job is to hold them accountable for any violations we find, and > that won't be changing. " > > The hundreds of deficiencies run the gamut from the bureaucratic, like > missing paperwork, to the problematic: not reporting within 24 hours > knowledge of an act of abuse, neglect or exploitation by a worker; > failing to make sure a patient's care plan is reviewed by doctors; > nurses or therapy supervisors not making home visits when required; not > checking properly for Medicare eligibility; and lacking written plans to > control infection and disease. > > But if no agency is about to be terminated and risk losing tens of > thousands, if not millions of dollars in Medicare money, why have an > inspection system? > > " Our top priority is the health and safety of the clients, " said DADS > spokeswoman Cecilia > Fedorov<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Cecilia+Fedorov%22>. > " Our investigations focus on the quality of care provided and when we > find that an agency is not in compliance with regulations, we require > timely and appropriate corrections. " > > Last month, the U.S. Department of Health and Human Services' Office of > Inspector > General<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Office+of+Inspector+General%22>rep\ orted > that contractors charged with detecting fraud have had a series of > problems that " affected their ability to identify potential fraud and > abuse " and track the collection of overpayments. > > *Bad coordination?* > > " The government has enough information that they should be able to find > this stuff. They ought to go look, " said > Hammon<http://www.chron.com/?controllerName=search & action=search & channel=news%2F\ houston-texas & search=1 & inlineLink=1 & query=%22+Hammon%22>, > director of clinical practice and regulatory affairs for the Texas > Association of Home Care & Hospice. " I think the big problem I see is > how the various government agencies coordinate. Each one says 'That's > not what I do' or 'I'm not funded.' " > > Some health care agencies counter that they're made scapegoats by the > inspections as both state and federal agencies are pressured to do > something about the nation's soaring Medicare bills. > > *'I go by the rules'* > > Edna Lewin, administrator of The Trend Health Care > Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22The+Trend+Health+Care+Services%22\ >, > says violations do not mean home health agencies or their workers are > not safe. > > The 32 " deficiencies " her company received in 2009 - the most by one > company in Houston - were all corrected. > > " You need to know the story, " she said. " I live above-board. If I > didn't, I wouldn't be in business. " > > Dorothy , a registered nurse who created her Lanoitan Home Health > Care of Texas in 1978, was cited for 21 deficiencies last year, all of > which she says were corrected immediately. > > " If you look at my record, it's superb, " she said. " I think I'm getting > the flak because there's so much fraud in home health care. I refuse to > be a part of it. I'm old school. I go by the rules. " > > In 2009, the General Accountability Office reported Medicare's spending > on home health care totaled $12.9 billion in 2006, up 44 percent in > 2002. > > It also zeroed in on several problems, some in Houston, including home > health care agencies' propensity to overstate a patients' condition in > order to get Medicare money. Nearly 700 patients deemed most severe > " were served by potentially fraudulent (home health care), " the audit > stated. > > Federal officials in Houston also are investigating kickback schemes and > billing for " services not rendered " but could not comment on specifics. > > " Law enforcement's efforts alone will not stop this fraud, " said Elvis > McBride, who supervises the FBI's Health Care Fraud Task Force in > Houston. " It takes CMS or Medicare to put edits in place to prevent > certain types of payouts. It takes education (for Medicare patients). " > > *Billing doubles* > > Even before Houston's explosive growth in home health care, federal > auditors noted that not only had the number of people getting Medicare > benefits doubled, but so did the number of times agencies billed for a > visit to a patient: from 36 times to 73. > > " I have a problem with the government not watching who is billing what, " > said Anita Bradberry, executive director of the Texas Association of > Home Care & Hospice. " It's not that home health is bad. Home health is > the solution to a lot of our health care problems. " > > via > chron.com<http://www.chron.com/news/houston-texas/article/Home-health-care-firms\ -breaking-rules-raking-in-2342534.php> > > > [image: App] On the go? > *Download Posterous Spaces* for your phone > <http://posterous.com/mobile> > Sent by Posterous. Is this spam? Report it > here<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions>. > Manage or unsubscribe email > subscriptions<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscri\ ptions> > Other > questions? We’d love to help. <http://help.posterous.com> > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 16, 2011 Report Share Posted December 16, 2011 [image: Posterous Spaces] [image: Your daily Update] December 16th, 2011 Seven characteristics of remarkable businesses<http://ptmanagerblog.com/seven-characteristics-of-remarkable-business\ e> Posted 1 day ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to PTManager<http://ptmanagerblog.com> [image: Like this post]<http://posterous.com/likes/create?post_id=86778369> Seven characteristics of remarkable businesses 15 Dec 2011| <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp/display_talkback.asp?referring_section=opinion & id=6366> <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp/display_talkback.asp?referring_section=opinion & id=6366> <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp#> <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp#> <http://www.addthis.com/bookmark.php?v=250 & winname=addthis & pub=ra-4db6d8725ea378\ 3f & source=tbx32-250 & lng=en-US & s=linkedin & url=http%3A%2F%2Fwww.management-issues.\ com%2F2011%2F12%2F15%2Fopinion%2Fseven-characteristics-of-remarkable-businesses.\ asp & title=Seven%20characteristics%20of%20remarkable%20businesses & ate=AT-ra-4db6d\ 8725ea3783f/-/-/4eea09b7b54b0e60/1 & frommenu=1 & uid=4eea09b7888a2e0c & ct=1 & tt=0> <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp#> <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp#> <http://www.management-issues.com/2011/12/15/opinion/seven-characteristics-of-re\ markable-businesses.asp#> Is your business 'remarkable'? I mean 'really remarkable'? What does that actually mean? What exactly makes a business 'remarkable'? Well, in simple terms, you could say it's anything that gets people 'remarking'. People don't talk about 'average' stuff, 'ok' stuff or 'not bad' stuff. They talk about 'outstanding', 'amazing', 'brilliant' and 'remarkable' stuff. They also talk about 'poor', 'terrible' 'disappointing' and 'remarkably bad' stuff. But it is the businesses that create positive remarks that we're focusing on in this article. So, 'remarkable' per se isn't the goal. Being remarked on for something that is poor or simply doing remarkable things for customers that don't make commercial sense or that exploit employees is not what this is about. Our experience suggests that leading a successful business, regardless of size, involves managing a balance between three things: 1. Creating sufficient devoted customers 2. Developing a team of committed, motivated and effective people 3. Maximising financial returns The challenges facing business leaders today are greater than ever. Ever rising customer and employee expectations, increasing competition (coming from further afield), greater transparency, reduction in trust and customer loyalty, the increasing pace and dramatic effects of change and squeezes on resources and margins are just some of the issues the leaders of today tell us they face. However, many businesses are not only surviving, but are thriving in this ever-changing environment. How are they doing it? What exactly makes them 'different'? How do they differentiate themselves and what can we learn from them? We call them 3D businesses and they are Dramatically and Demonstrably Different from their competitors. How do 3D businesses do it? Well, there are no magical answers, but there are clearly some common characteristics that differentiate remarkable businesses from the rest. We've identified seven themes on which to reflect and build a way forward for your own business. Your challenge is to work out what they mean for you, your business and how you lead your business; how you measure up; and – crucially - where you need to focus your resources and efforts. *1: They Have That Vision Thing!* 3D businesses know where they're going. All their people do too. They have a clear vision that inspires, engages and motivates everyone in the business (and often their customers too – that's what they buy into!). This vision isn't a set of figures or pie-in-the-sky dreams, but a meaningful picture of the future that creates focus, direction, passion and commitment. 3D businesses develop committed, motivated and effective people at every level – this does not happen by chance! They proactively get buy-in to their vision and values, ensure that everyone understands where they fit in and how they are doing. (Here's how Pret A Manger engage their people<http://www.businesszone.co.uk/blogs/andyhanselman/compete-or-get-beat/pre\ t-manger-great-recipe-success> ) *2: They Keep In Control! * In this ever increasingly fast-paced world, getting and keeping in control is critical. In 3D businesses the leaders ensure that the people get the information they need, when they need it and in a format they understand. This starts with the establishing and using meaningful Key Performance Indicators to lead and drive the business. They establish systems for feedback – from customers, communities and networks, as well as from employees. 3D businesses measure things like Net Promoter Score (How likely are you to refer us to your friends and colleagues?) and use these to monitor, drive (and reward) performance. This is not simply about ticking boxes. *3: It's About A Dramatic Difference! * 'Dramatic Difference' is " an unmatchable bundle of products, services, skills, methods and practices that differentiate a business from its competitors " . This can centre around what you do and /or how you do it. It is only any good if customers want it, recognise it, and are prepared to pay for it – better still, if they are prepared to pay more for it! (Here's how Apple does things<http://www.businesszone.co.uk/blogs/andyhanselman/compete-or-get-beat/pre\ t-manger-great-recipe-success> ) A 'Dramatic Difference' doesn't happen by chance. It often means breaking the rules, doing things that competitors aren't doing or can't do. The benefit of a 'Dramatic Difference' is that it really is remarkable – people do 'remark' about it. Dramatic Differences maximise the power of 'word of mouth' and, evermore crucially, 'word of mouse'! *4: It's All About The Experience* 3D businesses engage everyone in striving to create 'delighted' and 'devoted' customers who come back for more and tell others. It starts with being easy to buy from and easy to deal with. It means consistency and it means everyone focusing on customers wherever they are in the business and ensuring the systems and processes reinforce this. (Check out how Amazon do it<http://www.businesszone.co.uk/blogs/andyhanselman/compete-or-get-beat/amazon-\ are-number-1-customer-service-5-lessons-we-can-all-le> ) They strive to delight their customers which means exceeding customer expectations. By definition, doing this raises customer expectations. But 3D businesses relish and embrace this, and work hard to raise the bar. They make their customers feel valued. Customers have high expectations and consistently receive a great experience ('great' as defined by the customers, not the business!) It's about building a brand that stands for something and everything the business does needs to reflect and reinforce that. *5: Dialogue, not Diatribes! * 3D businesses recognise it's about maximising relationships and that this is not a one way thing.! They also know that customers need to be engaged. As a result, they develop dialogue, not diatribes, and work hard at ongoing engagement with their customers, their networks and their communities. That means interacting on a personal and business level and tailoring the experience specifically to each customer to help 'lock them in' with the 'ties that bind'. That can take the form of added value, thought leadership, education, interaction or innovation. They create, sustain and develop a recipe that works for their groups of customers (or 'tribes', as the best 3D businesses have). It's about letting customers recognise the personalisation and feel part of it. The more personalised it feels, the more difficult it is for competitors to get in there! (Here's how First Direct do it<http://www.businesszone.co.uk/blogs/andyhanselman/compete-or-get-beat/first-c\ lass-example-customer-delight> ) *6: Create An UBER Culture! * 3D businesses deliver and they deliver consistently. Their culture is tangible and customers experience that culture simply by talking to and interacting with employees, whether it's by email, on the telephone or face to face. Consistency comes from developing an UBER culture<http://tinyurl.com/d4oaxdg>that creates real competitive advantage and reinforce their Dramatic Difference. They ensure that: everyone Understands the culture and what's expected of the them and that employees consistently behave in line with that culture; Systems and processes are Built to reinforce and support that culture; employees are Encouraged, Enabled and Empowered to live the culture; and they Reward and Recognise those that live it! It's clear that this stuff doesn't happen by chance. 3D businesses proactively take steps that help develop an UBER culture. They Champion their Champions and crucially Challenge their Challengers – they find, recruit, develop, promote people who 'fit' and are not afraid to get rid of those that don't. (Here's Google's 'take' on this<http://www.businesszone.co.uk/blogs/andyhanselman/compete-or-get-beat/whos-\ responsible-culture-your-business> ) *7: Keep Working 'ON'! * 3D businesses recognise that Developing their Dramatic Difference is an ongoing process. They know that standing still actually means going backwards and that they need to drive and develop their Dramatic Difference continuously. It is not left to chance. It's about 'evaluatiON' – systematically checking on progress against goals and targets, it's about 'innovatiON' – having proactive processes to improve what they do, it's about 'communicatiON' - keeping people informed of plans and progress and it's about 'motivatiON', getting and keeping people on board (which takes us nicely back to 'Characteristic #1…. Get That Vision Thing!) Three Questions to get you '3D Thinking'. - What is your Dramatic Difference? - Do all your people know and live it? - Do your customers and potential customers recognise it? - And a bonus question: What are you going to DO as a result? *Conclusions* 3D Thinking is a way of doing things. It's a philosophy. It's an attitude. Crucially, it's one that is shared at every level of the business and drives performance. It looks different in every business, and there are no simple lists of things to do, or rules to follow. The challenge for every business today is to establish what its Dramatic Difference actually is, do everything it can to Demonstrate that Difference in everything it does and keep doing it. It's about leadership, it's about culture, it's about processes, and it's about PEOPLE! via management-issues.com<http://www.management-issues.com/2011/12/15/opinion/seven-\ characteristics-of-remarkable-businesses.asp> Healthcare Economist · What’s a ‘dual’?<http://ptmanagerblog.com/healthcare-economist-whats-a-dual> Posted 1 day ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to PTManager<http://ptmanagerblog.com> [image: Like this post]<http://posterous.com/likes/create?post_id=86779697> What’s a ‘dual’? December 15, 2011 in Medicaid<http://healthcare-economist.com/category/medicaidmedicare/medicaid-medi\ caidmedicare/>, Medicaid/Medicare<http://healthcare-economist.com/category/medicaidmedicare/>, Medicare<http://healthcare-economist.com/category/medicaidmedicare/medicare-medi\ caidmedicare/>| No comments <http://healthcare-economist.com/2011/12/15/whats-a-dual/#respond> Nine million individuals qualify for both Medicare and Medicaid health insurance. These individuals, known as dual-eligibles, rank among the most expensive Medicare and Medicaid beneficiaries. Duals are frequently hospitalized and often need long-term care. In fact, most state spending for dual eligibles focuses on long-term care supports and services. The federal government pays the bulk of care costs for dual eligibles. Of the $319.5 billion estimated as spent on duals in 2011, 80 percent ($256.6 billion) are federal dollars, more than two-thirds of which flowed through Medicare. Unnecessary hospital use is one of the main drivers of inflated Medicare spending on duals. One reason for this is that Medicare pays for all hospitalizations. Thus, State Medicaid Agencies have less of an incentive to prevent costly hospitalizations. Further, nursing homes also have an incentive to hospitalize duals. Nursing home who care for an individual after they are hospitalized receive a higher Medicare skilled nursing facility (SNF) rates rather than the lower Medicaid long-term care rates. Thus, nursing homes can increase their rates just by admitting their residents to teh hospital periodically. Additionally: *Dual eligibles experience far higher rates of “potentially preventable hospital admissions” than other Medicare beneficiaries: more than twice as high for pressure ulcers, asthma and diabetes; 52 percent higher for urinary tract infection; and over 30 percent higher for chronic obstructive pulmonary disease and bacterial pneumonia*. Many dual eligible individuals are enrolled in Medicare Special Needs Plans (SNP). [Dual eligibles constitute about a million of the 1.3 million people enrolled in SNPs.] Medicare pays these pays a capitated rate in exchange for providing a host of services to these beneficiaries. The Affordable Care Act established of the Medicare-Medicaid Coordinated Care Office (known internally at CMS as the Office of the Duals), which has launched a number of initiatives to better align the programs. A paper by Feder et al.<http://www.rwjf.org/files/research/72868qs68dualeligiblesfull20110930.pdf>ma\ kes the following recommendations: 1. finance nurse practitioners in nursing homes to coordinate frail residents’ care (United Healthcare’s Evercare program has already demonstrated, relative to control groups, that this strategy can cut hospitalizations and emergency room use in half); 2. apply performance standards, like those now applied to hospitals, to penalize SNFs with excessive rates of preventable hospitalizations for their residents (whether or not they are receiving SNF care). Source: - Judy Feder, Clemans-Cope, Coughlin, Holahan, Waidmann. “Refocusing Responsibility for Dual Eligibles: Why Medicare Should Take the Lead,<http://www.rwjf.org/files/research/72868qs68dualeligiblesfull20110930.pdf>\ ” Wood and the Urban Institute, October 2011. via healthcare-economist.com<http://healthcare-economist.com/2011/12/15/whats-a-dual\ /> 3 arrested in $90 million Medicare fraud scheme - Houston Chronicle<http://ptmanagerblog.com/3-arrested-in-90-million-medicare-fraud-schem\ > Posted about 16 hours ago by [image: _portrait_thumb] Kovacek, PT, DPT, MSA <http://posterous.com/users/1l1oCkDWEWjv> to PTManager<http://ptmanagerblog.com> [image: Like this post]<http://posterous.com/likes/create?post_id=86843879> 3 arrested in $90 million Medicare fraud scheme TERRI LANGFOR, HOUSTON CHRONICLE Copyright 2011 HOUSTON CHRONICLE. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.<http://www.chron.com/news/houston-texas/article/3-arrested-in-90-\ million-Medicare-fraud-scheme-2403896.php#license-4eea95035ba75> By TERRI LANGFORD, HOUSTON CHRONICLE Updated 11:37 p.m., Wednesday, December 14, 2011 Embedded media -- click here to see it.<http://ptmanagerblog.com/3-arrested-in-90-million-medicare-fraud-schem> Houston and Texas Embedded media -- click here to see it.<http://ptmanagerblog.com/3-arrested-in-90-million-medicare-fraud-schem> Embedded media -- click here to see it.<http://ptmanagerblog.com/3-arrested-in-90-million-medicare-fraud-schem> Embedded media -- click here to see it.<http://ptmanagerblog.com/3-arrested-in-90-million-medicare-fraud-schem> Comments (95)<http://www.chron.com/news/houston-texas/articleComments/3-arrested-in-90-mi\ llion-Medicare-fraud-scheme-2403896.php?gta=commentlistpos> Larger | Smaller Printable Version Email This<http://www.chron.com/news/houston-texas/article/3-arrested-in-90-million-Me\ dicare-fraud-scheme-2403896.php#> Georgia (default) Verdana Times New Roman Arial Font<http://www.chron.com/news/houston-texas/article/3-arrested-in-90-million-Me\ dicare-fraud-scheme-2403896.php#> Page 1 of 1 The owners of a Houston mental health program were arrested Wednesday, charged with trying to bilk Medicare<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22Medicare%22>out of $90 million for treatments that amounted to little more than patients " watching movies, playing bingo or engaging in other activities, " federal authorities contend. Mansour Sanjar, 78, and Cyrus Sajadi, 64, both physician owners of Spectrum Care in West Houston were charged in the alleged phony treatment scheme, which involved kickbacks to the owner of an assisted living facility in exchange for finding and funneling patients to the clinic. Chandra Nunn, 33, the owner of the home, also was arrested Wednesday. All three are charged with conspiracy to commit health care fraud and conspiracy to pay and receive illegal health care kickbacks. Since 2006, Center and Sajadi had been submitting bills to Medicare for supposed treatment at their " partial hospitalization program, " known as a PHP. The arrests come just two months after a Houston Chronicle<http://www.chron.com/?controllerName=search & action=search & channel=news\ %2Fhouston-texas & search=1 & inlineLink=1 & query=%22Houston+Chronicle%22>investigati\ on uncovered hundreds of millions in Medicare dollars spent to shepherd mentally fragile Texans by ambulance to mental health clinics and PHPs where patients claimed they watched TV and ate junk food. According to the indictment, the Spectrum Care owners submitted $90.4 million in claims starting in 2006 even though the PHP services " were not medically necessary, and in some cases, never provided. " Nunn's role was that of a patient broker, or what clinics call, a " marketer. " Sanjar is accused of paying Nunn with a $10,000 check in September 2010 to refer patients their way. The indictment accused all three defendants of paying Medicare beneficiaries cash and cigarettes if they came to Spectrum. Attempts to reach the three were unsuccessful. Texas Medical Board records show the agency disciplined Sajadi last February for failing to keep good records on a patient. The doctor did not admit to or deny the findings but agreed to complete in one year, eight hours of continuing education on medical record-keeping. In 2005, Sajadi was ordered by the board to complete nine hours of ethics courses, pay a $1,000 fine for violating a state law that requires a doctor who denies medical records to explain why the information was not provided. *Love ** & Caring Homes* The board also disciplined Sanjar in 2003 for overprescribing narcotics to a patient. The federal charges filed Wednesday did not list the name of Nunn's facility. Public records show she is the registered agent for an operation called Love & Caring Homes Inc., that was incorporated on June 28, 2010. It is unclear whether the home was licensed by the state. Spectrum is one of nearly two dozen community mental health centers and PHPs in County that have collected millions in Medicare dollars, but require no license to operate in Texas, the Chronicle's investigation in October found. The patients are mostly poor, some near homeless, who live in personal care homes, assisted living facilities - like that owned by Nunn - or apartments arranged by caretakers and caseworkers. *Ferrying patients* The paper's investigation also documented that the burgeoning business of mental health care in Houston is further fueled by the local private ambulance industry, which ferries patients to therapy and also bills Medicare. Nearly $500 million was paid by Medicare to private EMS operators in County over a six-year period, records show. By the federal government's own rules, many of these EMS transports are not medically necessary and should not even qualify for federal dollars. Wednesday's arrests were part of a larger operation involving several federal and Texas agencies including the Federal Bureau of Investigation<http://www.chron.com/?controllerName=search & action=search & channel=\ news%2Fhouston-texas & search=1 & inlineLink=1 & query=%22Federal+Bureau+of+Investigat\ ion%22>, U.S. Health and Human Services<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22U.S.+Health+and+Human+Services%22\ >' Office of Inspector General<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Office+of+Inspector+General%22>, the Texas Attorney General's Medicaid Fraud Unit and the U.S. Attorney's Office for the Southern District of Texas<http://www.chron.com/?controllerName=search & action=search & channel=news%2Fh\ ouston-texas & search=1 & inlineLink=1 & query=%22Office+for+the+Southern+District+of+\ Texas%22> .. " This case is another excellent example of the partnership and cooperation between the U.S. Attorney's Office, the Department of Justice and our investigating agencies, " said U.S. Attorney Magidson<http://www.chron.com/?controllerName=search & action=search & channel=news%\ 2Fhouston-texas & search=1 & inlineLink=1 & query=%22+Magidson%22>of the Southern District of Texas. " We will continue to work closely with each other to ensure those who engage in such fraudulent health care practices are brought to justice. " According to Medicare data obtained by the Chronicle, Spectrum Care received more than $1 million from Medicare in 2010. The indictment filed Wednesday indicates Spectrum Care has been paid more than $6.5 million since 2006. Private ambulance data obtained by the Chronicle also shows private ambulances making trips to Spectrum collected more than $19 million in Medicare money in recent years. *More charges?* When asked about whether ambulance companies would be charged in relation to Spectrum's scheme, U.S. Department of Justice spokeswoman Alisa Finelli<http://www.chron.com/?controllerName=search & action=search & channel=news%2\ Fhouston-texas & search=1 & inlineLink=1 & query=%22Alisa+Finelli%22>would say only that " our investigation into Spectrum is ongoing. " A report released Wednesday, based on 2011 Department of Justice data, shows Houston is second in the nation for Medicare fraud prosecutions. When grouped with Miami, these two federal court districts accounted for more than one of every five health care fraud prosecutions. via chron.com<http://www.chron.com/news/houston-texas/article/3-arrested-in-90-milli\ on-Medicare-fraud-scheme-2403896.php> [image: App] On the go? *Download Posterous Spaces* for your phone <http://posterous.com/mobile> Sent by Posterous. Is this spam? Report it here<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscriptions>. Manage or unsubscribe email subscriptions<http://posterous.com/emails/gspsqucxgqviGogjvCufJwAxBxkgmH/subscri\ ptions>. Other questions? We’d love to help. <http://help.posterous.com> Quote Link to comment Share on other sites More sharing options...
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