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December 8, 2011

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[image: Your Daily Update] December 8th, 2011 UPDATE: The Epidemic

of Florida Medicare Fraud (Prison Terms) -

Forbes<http://ptmanagerblog.com/update-the-epidemic-of-florida-medicare-fraud>

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UPDATE: The Epidemic of Florida Medicare Fraud (Prison Terms)

*This is an UPDATE of an article originally published in Street Sweeper on

August 24,

2011<http://www.forbes.com/sites/billsinger/2011/08/24/the-epidemic-of-florida-m\

edicare-fraud/>.

*

*Healthcare services is a booming business and one that is often victimized

by fraud. Not only can participants in the healthcare sector perpetrate

fraud upon government payors and patients, but such organizations may also

be victimized by unscrupulous practices involving demands for kickbacks,

bribes, and other frauds. Hospitals, nursing homes, clinics, and other

service providers have come to depend upon a complex inter-relationship

among patients, providers, insurers, and government payors. Healthcare has

become big business, with publicly traded companies such as HCA Holdings,

Inc.; Tenet Healthcare; Community Health Systems, Medco Health Solutions;

Humana, and others combining the provision of healthcare with an eye on the

bottom line. When allegations of fraud circle around such listed companies

(be they victims or participants), such news often highlights the crisis

proportion to which healthcare costs have exploded and demand (particularly

among the aging Baby Boomer population) is soaring. Clearly, it is in the

best interest of both the users and providers of healthcare to ensure that

the industry is well policed and fraud rooted out and punished.*

Move up Move down

<http://www.forbes.com/sites/billsinger/2011/11/02/12-defendants-named-in-ny-med\

icare-fraud-cases/><http://blogs.forbes.com/billsinger/>

<http://blogs.forbes.com/billsinger/>

On February 10, 2011, federal prosecutors indicted 21 Miami-area residents

(including two doctors, six nurses, eleven patient recruiters) in

connection with their alleged participation in a $25 million home health

care Medicare fraud scheme. The *Indictment* alleged charges including

conspiracy to commit health care fraud, making false statements, and

soliciting kickbacks.

*Note: *An *Indictment* is merely an accusation and defendants are presumed

innocent unless and until proven guilty in a court of law.

*The Defendants*: Nunez, M.D., Francisco , M.D., Eneida Fry,

L.P.N, Pineiro, R.N., Maritza Vidal, R.N., a/k/a “Maritza Casas,”

Ignacio Angulo, L.P.N., Farah -, R.N., a Morciego, R.N.,

Odalys Alvarez-Medina, Lesder Casanova, ez, ,

Beatriz -Cruz, a Rivas, Ros, Fidel Castro, Barbara ,

Vicente Guerra, Alvarez, ndra Alonso and Licet .

Medically Unnecessary Services

The *Indictment *alleges that ABC Home Health, Inc. (“ABC”) and Florida

Home Health Care Providers, Inc. (“Florida Home Health”) referred Medicare

beneficiaries to Drs. Nunez and for medically unnecessary home

health care, and that the doctors received illegal kickback payments from

the owners and operators of ABC and Florida Home Health in consideration

for their signing prescriptions for therapy and home health services.

Additionally, the doctors received Medicare payments for home health care

services, including office visits and diagnostics tests.

It is further alleged that the defendant nurses, recruiters, and employees

also received kickbacks and bribes for recruiting Medicare beneficiaries to

be referred for home health services through doctors working with ABC and

Florida Home Health (pointedly, Defendant Licet was charged with

distributing kickbacks to patient recruiters on behalf of the owners of ABC

and Florida Home Health).

On February 17, 2011, federal prosecutors announced the arrest of the

Defendants.

Guilty Pleas

On August 23, 2011, Defendant Nunez, 63, a physician who owned two

medical offices, pleaded guilty in federal court in Miami to one count of

conspiracy to commit health care fraud. According to his plea, Nunez

admitted to having provided home health care and therapy prescription

referrals to ABC and Florida Home Health from about January 2006 until

March 2009, and that he knew co-conspirators at ABC and Florida Home Health

had operated those agencies in order to fraudulently bill Medicare for

expensive physical therapy and home health care services (which he and

other doctors had prescribed) that were medically unnecessary and/or were

never provided.

Federal prosecutors alleged that Nunez furthered the scheme by falsifying

patient files with descriptions of non-existent medical conditions,

including hand tremors, unsteady gait and poor vision. Those specific

symptoms were reported by Nunez in order to create the false impression

that the subject patients were unable to self-inject insulin and were

homebound, which would qualify them for Medicare home health care benefits.

As a result of Nunez’s fraud, Medicare was defrauded to the extent of $1.5

million in home health care services that were medically unnecessary or

never even provided.

Nunez is scheduled to be sentenced in December 2011, at which time he faces

a maximum prison sentence of 10 years, fines, supervised release, and

forfeiture. He faces sentencing in December 2011.

Defendants ndra Alonso, a Morciego and Vicente Guerra previously

pleaded guilty for their roles in the fraud scheme.

UPDATE

On December 6, 2011, after having each pleaded guilty to one count of

conspiracy to commit health care fraud, the following defendants were

sentenced in District Court in Miami:

- * Nunez*: 40 months in prison; ordered to pay $1.1 million in

restitution;

- *a Morciego*: 24 months in prison; ordered to pay $296,000 in

restitution;

- *Eneida Fry*: 24 months in prison; ordered to pay $395,000 in

restitution.

Also, each of these defendants was sentenced to three years of supervised

release and ordered to pay restitution jointly and severally with the

co-defendants in this case and in a separate but related Medicare fraud

case.

Another Case in Point

In a separate development, on August 23, 2011, after a six-day trial in the

Southern District of Florida, a federal jury convicted Judith Negron, 40,

owner of the Miami-area mental health care company American Therapeutic

Corporation (“ATC”), of 24 felony counts including conspiracy to commit

health care fraud, health care fraud, conspiracy to pay and receive illegal

health care kickbacks, conspiracy to commit money laundering, money

laundering and structuring to avoid reporting requirements.

ATC ran partial hospitalization programs (“PHPs”) (a form of intensive

treatment for severe mental illness) in seven different locations

throughout South Florida and Orlando. Negron and her co-conspirators were

further charged with using a related company, American Sleep Institute

(ASI), to submit additional fraudulent Medicare claims.

It was alleged that Negron’s scheme resulted in the submission of over $205

million in fraudulent claims to Medicare.

via

forbes.com<http://www.forbes.com/sites/billsinger/2011/12/07/update-the-epidemic\

-of-florida-medicare-fraud-prison-terms/>

Healthcare Economist · ICD-10 is coming…ICD-10 is

coming<http://ptmanagerblog.com/healthcare-economist-icd-10-is-comingicd-10-i>

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ICD-10 is coming…ICD-10 is coming

December 7, 2011 in

Data<http://www.instapaper.com/m?u=http%3A%2F%2Fhealthcare-economist.com%2Fcateg\

ory%2Fdata%2F>|

Many health insurers (public and private) reimburse doctors based on the

patient’s diagnosis. If you treat a patient for a more severe illness

during a inpatient stay, Medicare pays you more money. Physicians use

procedures to bill insurers for the care they provided.

How do insurers know the patient’s diagnosis and the procedures providers

perform? The answer is the International Classification of Disease

(ICD<http://www.instapaper.com/m?u=http%3A%2F%2Ficd9cm.chrisendres.com%2F>)

taxonomy. Currently, this system is in its ninth iteration, but it will

soon be replaced by ICD-10 (the tenth revision) codes. By January 1, 2012,

CMS will mandate that all electronic health record transaction use the

ICD-10 system and by October 1, 2013 providers will all have to use the ICD-10

diagnosis and procedure codes for their claim

submissions<http://www.instapaper.com/m?u=https%3A%2F%2Fwww.cms.gov%2FICD10%2FDo\

wnloads%2FICD10IntroFactSheet20100409.pdf>

..

What’s new about the ICD-10 compared to the ICD-9? Read more below to find

out.

Diagnosis Codes

For example, if a patient is seen for treatment of a burn on the right arm,

the ICD-9 diagnosis code does not distinguish that the burn is on the right

arm. If the patient is seen a few weeks later for another burn on the left

arm, the same ICD-9 diagnosis code would be reported. Additional

documentation would likely be required for a claim for the treatment to

explain that the burn treated at this time is a different burn from the one

that was treated previously. In the ICD-10 diagnosis code set, characters

in the code identify right versus left, initial encounter versus subsequent

encounter, and other clinical information.

*ICD-9* *ICD-10* 3-5 characters 3-7 characters 13,000 codes 68,000

available codes First digit may be alpha (E or V) or numeric; digits 2-5

are numeric Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are

alpha or numeric Lacks detail very specific Lack laterality (left vs.

right) Has laterality

The ICD-10 code structure can be characterized as follows:

- Characters 1-3 – Category

- Characters 4-6 – Etiology, anatomic site, severity, or other clinical

detail

- Characters 7 – Extension

For instance:

S52 Fracture of forearm S52.5 Fracture of lower end of

radius S52.52 Torus fracture of lower end of radius

S52.521 Torus fracture of lower end of right radius

S52.521A Torus fracture of lower end of right radius, initial encounter

for closed fracture

In this example, S52 is the category, the sixth category indicates

laterality (i.e., 1=right), and the seventh character that this is the

initial encounter.

Procedure Codes

Whereas the diagnosis codes describe the patient’s conditions, procedure

codes describe the services the physiican provides. In the new ICD-10

procedure coding system, each digit of the procedure code tells you a

different piece of information. Specifically,

- 1st digit: Name of Section

- 2nd digit: Body System

- 3rd digit: Root Operation

- 4th digit: Body Part

- 5th digit: Approach

- 6th Digit: Device

- 7th Digit: Qualifier

For example, the code for right knee joint replacement is *0SRC0JZ* which

means the following:

- 0 = Medical and Surgical Section

- S = Lower Joints

- R = Replacement

- D = Knee Joint, Right

- 0 = Open

- J = Synthetic Substitute

- Z = No Qualifier

Below is a chart comaring the ICD-9 and ICD-10 procedure codes.

*ICD-9* *ICD-10* 3-4 numbers in length 7 alpha-numeric characters in length

~3,000 cods Approximately 87,000 codes available Lacks laterality Has

laterality Lacks descriptions of methodology and approach for procedures

Contains descriptions of methodology and approach for procedures

Source: American Medical Association (AMA) Fact Sheet, “The Differences

between ICD-9 and ICD-10,” June 2, 2010.

*Tags:*

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%2Fcoding%2F>,

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ICD-10<http://www.instapaper.com/m?u=http%3A%2F%2Fhealthcare-economist.com%2Ftag\

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tag%2Fprocedure%2F>

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