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FWA (KS)- Johnson Co. woman ordered to pay $31K in restitution for Medicaid Fraud

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: You gave Carol $31k for false personal care attendant claims. She did not say thank you.

 
 

Clipped from: https://www.wibw.com/2023/01/26/johnson-co-woman-ordered-pay-31k-restitution-medicaid-fraud/

 
 

A Johnson Co. woman has been sentenced for Medicaid fraud and has been ordered to pay $31,000 in restitution to the Kansas Medicaid program.(Office of the Attorney General)

JOHNSON CO., Kan. (WIBW) – A Johnson Co. woman has been sentenced for Medicaid fraud and has been ordered to pay $31,000 in restitution to the Kansas Medicaid program.

Kansas Attorney General Kris Kobach announced Wednesday that Carol Elaine Hensley, 63, of Overland Park, has pleaded guilty to one count of making a false claim, statement, or representation to the Medicaid program and one count of unlawful acts concerning computers in Johnson Co. District Court. The court judge sentenced Hensley to 24 months behind bars, but that sentence has been suspended; Hensley has now been ordered to serve one year of supervised probation and pay $31,174.49 in restitution.

According to Kobach’s office, investigators looking into Hensley’s case discovered that she served as a personal care attendant for her two adult children, who also happen to be Medicaid beneficiaries. As investigators looked further, they found that Hensley submitted claims for payment to the Medicaid program as if she were providing services to her adult children from January 1, 2018, to February 28, 2022. However, investigators said that Hensley was instead working at different jobs and signed up her adult children for in-day support services.

Kobach said that Hensley’s case is part of an ongoing, cooperative effort between the Kansas Attorney General’s office and the U.S. Department of Health and Human Services/Office of Inspector General called “Operation Keeping Them Honest.” The collaboration is focused on investigating fraudulent billing to the Medicaid program for personal care services in the homes of Medicaid beneficiaries.

Kobach’s office said that nine cases have, so far, been filed within the courts, and five cases have reached the sentencing phase.

The Attorney General’s office said that the other cases are ongoing, joint investigations conducted by the federal and state authorities and prosecuted by Kobach’s Medicaid Fraud and Abuse Division.

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FWA (PA)- Three Montgomery County dentists bilked Medicaid for millions, a federal indictment says

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Three brothers ran an absolutely massive dental empire, full of fraud. The thing that finally got em collared? Implanting unapproved medical devices they developed in the mouths of Medicaid patients. You paid them at least $4M in fraud just for the embezzling part.

 
 

 
 

Clipped from: https://www.inquirer.com/news/medicaid-fraud-dentists-bhaskar-savani-biranjan-savani-montco-pennsylvania-federal-indictment-20230125.html

Prosecutors say Bhaskar, Arun, and Niranjan Savani broke at least a dozen laws in their efforts to generate millions in profits between 2009 and last year.

 
 

Dreamstime / MCT

Federal authorities have accused the owners of a Montgomery County-based dental conglomerate of running their businesses like a criminal enterprise — bilking millions of dollars from government health-care programs, illegally importing foreign workers, and endangering patients by implanting unapproved medical devices in their mouths for profit.

Brothers Bhaskar Savani, 56, of Ambler; Arun Savani, 55, of Blue Bell; and Niranjan Savani, 51, of Ambler, broke at least a dozen laws in their efforts to generate more than $316 million in profits between 2009 and last year, prosecutors said in a sprawling 102-page indictment unsealed Tuesday.

Investigators also accused the siblings of laundering their illicit proceeds through hundreds of bank accounts and embezzling more than $4 million from nearly three dozen companies to cover personal expenses like a Hawaiian vacation home, college tuition for their children, and utilities and tax payments on their homes.

The charges against the Savanis and nine codefendants — which include counts of racketeering conspiracy, visa and health-care fraud, money laundering, and conspiracy to distribute misbranded medical devices — are the result of a years-long investigation by nearly a dozen state and federal agencies into the empire the Savanis oversaw from a nondescript office park in Fort Washington.

Attorneys for the brothers balked at the government’s accusations, calling them a distortion of the Savani brothers’ companies and careers that now threatens to send them to prison for up to 20 years on the most serious count they face.

“The three brothers look forward to their day in court and cherish the concept that in this country that they have made their home, people are presumed innocent,” the lawyers said in a statement.

Viewed through a certain lens, the business empire the Savanis created since their arrival in the United States is an unquestionable success.

After emigrating from India, Bhaskar Savani, known as “Dr. B,” earned his dental degree from Temple University in 1995 and quickly set about building his practice into an empire.

Aside from his dental practices, he became an evangelist for the importation of Indian mangoes, persuading the U.S. Department of Agriculture in 2007 to lift a 18-year ban, and expanded into real estate, becoming one of the financial backers of a proposed indoor velodrome in Valley Forge in 2006.

Meanwhile, he brought on brothers Arun, to oversee financial affairs for the businesses, and Niranjan, a fellow dentist, to help him expand his core dental businesses into an empire.

Today, they oversee more than 50 dental practices across states including Pennsylvania, New Jersey, Iowa, and South Carolina and a bevy of associated companies focused on research and development of dental implant devices, employ more than 400 people, and serve thousands of patients each year, many from inner cities and other underserved areas where there are few practicing dentists.

Prosecutors say serving those low-income clients — especially those enrolled in government-funded health-care programs like Medicaid — was central to the Savani brothers’ grift.

Among other crimes alleged in the indictment, the Savanis are accused of relying on uncredentialed dentists to treat patients in violation of Medicaid rules.

Savani businesses allegedly required those dentists to falsely state that other licensed dental providers employed by their companies had performed treatments billed to Medicaid and required them to pay kickbacks to the doctors whose names they were using.

For instance, prosecutors said, between 2014 and 2018 Savani businesses submitted roughly 2,600 claims falsely stating that Niranjan Savani was the dentist performing procedures, when he was not even in the country at the time they were performed.

When authorities would catch on to the scheme and cancel Medicaid contracts with one Savani company, they’d have an employee open another — running it in name only — to land those contracts again, according to the indictment.

Between 2013 and last year, just one of those businesses — Allentown-based Smilekrafters Dental — earned roughly $80 million in Medicaid reimbursements under a contract it had fraudulently obtained, the document states.

But prosecutors said even as the Savanis were taking advantage of weaknesses in the Medicaid oversight, their companies were also exploiting foreign-born employees who worked for them.

The brothers recruited workers from India and elsewhere for jobs in the United States through a program meant to hire employees with specialized skills such as scientists, programmers, researchers, and analysts.

However, investigators say, many of the people for whom they helped secure visas ostensibly for jobs in the Savanis’ research-oriented companies, ended up in nonspecialized jobs running dental offices or as administrators being paid less than prevailing wage and required to kick back portions of their salaries to others in the companies.

The indictment paints one of the businesses run by the Savanis — Fort Washington-based EZ Biotek — as a front, filled with nonfunctioning lab equipment meant to fool immigration authorities when they would show up for periodic visits to verify those employees were working in active dental or chemistry research labs.

Still, some of the Savani companies’ research efforts were legitimate — including those at Fort Washington-based Osseolink USA, which starting in 2017 began developing a new kind of synthetic tooth implant for use in patients.

Though the implants had not yet received approval from the Food and Drug Administration, the brothers’ companies shipped prototypes in bags marked “not for human use” to several dental offices, where dentists employed by the brothers used them in the mouths of at least 18 patients, prosecutors said.

“Health care providers, who have a duty to practice in their patients’ best interests, are especially deceitful when they commit Medicaid fraud,” said Maureen R. Dixon, head of the U.S. Department of Health and Human Services’ Office of Inspector General.

In addition to the criminal charges, prosecutors are seeking forfeiture of some 27 properties linked to the Savanis and their businesses in Philadelphia, Montgomery, Delaware, Bucks, and Lehigh Counties as well as Iowa and Hawaii.

The brothers were released on bail pending trial after a brief initial court appearance Tuesday.

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FWA (MN)- In-home care provider investigated for $4M in Medicaid fraud

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Bridges MN is under investigation for billing for home care services on properties that it owns. Current estimate is at least $4M in fraudulent billing.

 
 

 
 

Clipped from: https://kstp.com/kstp-news/top-news/in-home-care-provider-investigated-for-4m-in-medicaid-fraud/

A St. Paul-based home health care company is being investigated by the Minnesota Attorney General’s Office for fraudulently overbilling the state’s Medicaid program, which is designed to support low-income residents and people with disabilities.

State investigators took computers, financial reports, rental agreements, and other documents from Bridges MN on Thursday, according to court documents filed last week. Authorities say they have already tracked $4 million in fraudulent billing over five years, with the possibility of more instances of fraud expected, according to a search warrant.

Bridges provides in-home care to more than 40 individuals across Minnesota, according to the warrant. Since 2016, the company has been reimbursed over $146 million for services provided to Medicaid recipients.

The Minnesota Department of Human Services previously revoked Bridges MN’s license after finding instances of maltreatment and non-compliance. State records show that the company is appealing that decision and has continued to operate.

DHS pieced together possible fraud after reviewing years of financial documents, daily care notes, and interviews with whistleblowers. The investigation comes after years of warnings from the agency, which told Bridges MN executives in 2019 the company was at risk of billing fraud if it provided services outside of the federally approved waiver plans.

 
 

Minnesota Attorney General Keith Ellison speaks during a press conference regarding the proposed merger between Fairview and Sanford Health on Nov. 22, 2022. (KSTP-TV)

After two years of notices, “Bridges continued to bill for services… well after receiving the first notice of non-compliance,” investigators with the Attorney General’s Office said.

No one from Bridges MN has been charged with a crime.

In a statement to 5 INVESTIGATES, an attorney for Bridges MN said the company “denies any wrongdoing and believes that the allegations in the search warrant affidavit will prove to be incorrect,” adding: “While we proactively address these allegations, we will continue to focus our complete attention on the clients and caregivers who look to us for support.”

Company executives are also facing accusations of billing for services on properties they own or have a financial stake in, which is illegal for “own-home” services in Minnesota.

The state investigation found Bridges MN was billing for services even when some of its residents were sleeping, going to online school, or going to church.

A case worker told the company in a January 2021 email: “it is fraudulent billing, and I can’t make that any different,” according to the warrant.

Asked by investigators about the documented overbilling, co-owner, Chief Financial Officer and Vice President of Finance Scott Loe told DHS that his company “does not consistently review supporting documentation to determine how to bill.” Loe also told investigators it would be “a good question” for other staffers, the warrant states.

Bridges MN is in the process of being sold to another company, Caregiver, which state officials said they believe will provide the same types of services. 

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FWA (NH)- Nashua man indicted on Medicaid fraud charges

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Ron Anderson got NEMT trips for fake medical visits. Where was he going? Is this a cheat code to use NEMT for Uber?

 
 

 
 

Clipped from: https://www.unionleader.com/news/courts/nashua-man-indicted-on-medicaid-fraud-charges/article_caabf5ed-7113-5550-a63a-36666297c4c8.html?block_id=849463

 
 

 
 

A Merrimack County Grand Jury has indicted a Nashua man on charges of Medicaid fraud, prosecutors said Tuesday.

Attorney General John M. Formella said in a news release Ronald Anderson, 46, of Nashua, has been indicted on charges of theft by deception and Medicaid fraud — false claims in connection with allegedly fraudulent claims for non-emergency medical transportation services.

The indictments allege that between July 7, 2020 and Feb. 20, 2022, Anderson fraudulently requested trips through the Medicaid non-emergency medical transportation program related to medical visits that did not exist.

Prosecutors claim Anderson acted with the intent to defraud New Hampshire Medicaid, receiving over $1,500 in Medicaid funds in connection with the alleged scheme.

Anderson will be arraigned in the Merrimack County Superior Court on a date to be determined.

The theft by deception charge carries a maximum penalty of 7 1/2 to 15 years in state prison and a $4,000 fine.

The maximum penalty for the Medicaid fraud charge is 3 1/2 to 7 years in jail and a $4,000 fine.

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FWA (MA)- DePuy Synthes, Inc. Agrees to Pay $9.75 Million to Settle Allegations Concerning Kickbacks Paid to Massachusetts Orthopedic Surgeon

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A J&J company is paying out $10M over using free implants and tools to a spinal surgeon that cause him to prefer their products whenever he submitted claims for Medicaid bennies.

 
 

 
 

Clipped from: https://www.justice.gov/opa/pr/depuy-synthes-inc-agrees-pay-975-million-settle-allegations-concerning-kickbacks-paid

Medical device manufacturer DePuy Synthes, Inc. (DePuy), a subsidiary of Johnson & Johnson, has agreed to pay $9.75 million to resolve allegations it violated the False Claims Act by paying kickbacks to an orthopedic surgeon based in Massachusetts to induce his use of DePuy products.

The settlement announced today resolves allegations that DePuy violated the Anti-Kickback Statute (AKS) and caused the submission of false or fraudulent claims to Medicare by paying the orthopedic surgeon kickbacks in the form of free spinal implants and tools for use in surgeries that the surgeon performed overseas to induce that surgeon to use DePuy products in surgeries performed in the United States. As part of the settlement, DePuy has admitted that from at least July 2013 through February 2018, DePuy, acting through certain former sales representatives, gave the Massachusetts surgeon thousands of dollars’ worth of free DePuy implants and instruments, including cages, rods, screws, plates, and surgical instrumentation, that the surgeon used to perform surgeries overseas for patients who were not federal health care beneficiaries. Of the $9.75 million to be paid by DePuy, approximately $7.23 million will be returned to the federal government, and approximately $2.52 million will be returned to Massachusetts, which jointly funded claims for surgeries involving DePuy devices that were submitted to the Massachusetts Medicaid program.

The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare and other federally funded programs. The statute is intended to ensure that medical providers’ judgments are not compromised by improper financial incentives and are instead based on the best interests of their patients.

“Medical device manufacturers are prohibited from providing free items to induce a physician to use their devices,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “When medical devices are used in surgical procedures, patients deserve to know that their device was chosen based on quality of care considerations and not on improper inducements from manufacturers.”

“Today the United States resolves allegations that DePuy provided over $100,000 worth of free product to a surgeon in order to secure and reward that physician’s continued business,” said U.S. Attorney Rachael S. Rollins for the District of Massachusetts. “Unlawful kickbacks can severely distort medical judgment as well as the market for medical devices. The millions of patients that depend on our health care system deserve untainted medical decisions. This settlement reflects our commitment to stamping out illegal kickbacks.”

“The American people, as both taxpayers and consumers, expect medical device manufacturers like DePuy to abide by relevant laws and regulations. When such health care companies provide illegal kickbacks in order to boost profits, their actions erode public confidence in the health care system, can compromise the patient-physician relationship, and waste government health program funding,” said Special Agent in Charge Phillip M. Coyne of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). “In close cooperation with our law enforcement partners, we will continue to thoroughly investigate allegations of fraud to protect both federal health care programs and those served by them.”

“Today’s settlement makes it crystal clear that it is illegal for medical device companies to provide physicians with free medical products to win business and boost their bottom line through illegal kickback schemes,” said Special Agent in Charge Joseph R. Bonavolonta of the FBI Boston Division. “Every year, health care fraud costs taxpayers billions of dollars. It is not a victimless crime and this unscrupulous scheme orchestrated by DePuy is just one example of how the FBI and our partners are working hard every day to protect both patients and taxpayers.”

The lawsuit was originally filed under the qui tam or whistleblower provisions of the False Claims Act by Aleksej Gusakovs, who is a former sales representative for DePuy. Under those provisions, private parties, known as relators, can file an action on behalf of the United States and receive a portion of the recovery. The qui tam case is captioned United States et al. ex rel. John Doe v. Johnson & Johnson, et al., No. 17-cv-11502 (D. Mass.). As part of today’s resolution, Gusakovs will receive approximately $1.37 million.

The settlement was a result of a coordinated effort between the Civil Division’s Commercial Litigation Branch (Fraud Section) and the U.S. Attorney’s Office for the District of Massachusetts. The HHS-OIG provided investigative support.

The government’s pursuit of these matters illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services, at 800HHSTIPS (800-447-8477).

The matter was handled by Senior Trial Counsel Benjamin C. Wei of the Civil Division and Assistant U.S. Attorneys Jessica Weber and Andrew Caffrey for the District of Massachusetts.

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

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FWA(MA): Mother of disabled young man collected more than $120K while he was in jail, group home

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Jessica Parisella used her disabled to son to rack up $150k of bogus Medicaid claims for a family friend and for another ABA company.

 
 

 
 

Clipped from: https://www.salemnews.com/news/ag-mother-of-disabled-young-man-collected-more-than-120k-while-he-was-in-jail/article_0d89baea-9c33-11ed-9117-b3dd604771e7.html

BEVERLY — During the summer and fall of 2020, Jessica Parisella and Don Martel were fighting a plan to move Parisella’s disabled son to a group home.

Jonathan Jutras, now 22, had been a client of the Department of Developmental Services for years, receiving services from providers like Martel, whose company was being reimbursed by MassHealth, the state’s Medicaid program, for counseling Jutras.

His mother, meanwhile, acted as her son’s surrogate to collect MassHealth funds to pay a personal care assistant, a family friend.

After Jutras went to jail in 2019, those payments should have stopped, prosecutors say.

And that family friend? He lives on Nantucket, and, prosecutors say, agreed to sign blank time sheets for Parisella — who allegedly kept all of the money, totaling $120,648 — starting as far back as 2017.

Martel and his company, meanwhile, allegedly billed the state $35,045 for applied behavioral analysis services that he and his employees could not have provided to Jutras while he was in custody in 2019.

Parisella, 42, of Danvers, and Martel, 67, of Georgetown, both pleaded not guilty to charges of felony larceny and Medicaid fraud during their arraignments Tuesday in Salem Superior Court.

Both appeared in court in response to summonses that were sent after their indictments last month by an Essex County grand jury.

Because of that, Assistant Attorney General William Champlin did not seek bail for the pair — but did ask Judge Thomas Drechsler to set several conditions of release, including no contact with each other.

But both Parisella and Martel balked at some of the other proposed conditions — leading Drechsler to schedule a hearing next week on the issue.

Martel, who was deemed indigent and appointed a lawyer from the Committee for Public Counsel Services, did not want to agree to a condition that he not bill MassHealth for any services.

Nathaniel Spinney, the public defender, told the judge that such a prohibition would prevent Martel from earning money. “That is my client’s entire ability to work,” Spinney told the judge.

And Parisella objected to an order that she have no contact with the Nantucket man, Richard Jervah, while the case is pending.

Drechsler, citing the provisions of the state’s bail law, told lawyers for the pair and the prosecutor that he has no authority to impose conditions of release unless the defendants agree to them.

He also, however, told them that he would allow the attorney general’s office to change its request and seek bail for the pair.

He scheduled another hearing for Feb. 1.

Jutras suffers from several physical and mental disabilities, including a chronic lung condition and congenital hip issues, as well as being diagnosed on the autism spectrum, bipolar and attention deficit hyperactivity disorders. His mother told The Salem News in 2020 that Jutras functions at the level of someone half his age.

In 2019, he was arrested and charged with indecent assault and battery on three boys at a Beverly playground, after getting out of the Beverly apartment where his older brother was supposed to be watching him.

But his developmental issues made him incompetent to stand trial.

At the same time, officials were concerned that if released, Jutras could pose a danger.

His physical and mental health issues also made him vulnerable inside the jail, however, and his attorney sought and found a placement in a supervised forensic group home operated by Turning Point Inc. But Parisella and Martel objected to that plan, instead proposing that Martel be given funds to start a new program.

The dispute led to a months-long fight over guardianship.

Jutras was eventually moved to a supervised program in Boston, and later to a supervised group home, where he now lives. The charges against him remain open.

While their cases involve the same profoundly disabled young man, Champlin stressed that Parisella and Martel are not co-defendants and that their alleged schemes were separate.

Courts reporter Julie Manganis can be reached at 978-338-2521, by email at jmanganis@salemnews.com or on Twitter at @SNJulieManganis

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MCOS; FWA; MEDICARE- Insurers Are Fighting To Protect Their Medicare Fraud

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The big players in the Medicare Advantage upcoding / HCC scams are not really wanting there to be a true-up for the estimated $650M they got in overpayments about 10 years ago.

 
 

Clipped from: https://www.levernews.com/insurers-are-fighting-to-protect-their-medicare-fraud/

 
 

This year, for the first time, a majority of seniors eligible for Medicare will be on privatized Medicare Advantage plans. Now, the insurance companies raking in giant profits from these for-profit plans are mounting a pressure campaign and planning to sue the government to protect years of overpayments they’ve extracted from Medicare.

A cash cow for big insurers, the for-profit version of Medicare has not been a great deal for the American public. Medicare Advantage plans cost the government more per beneficiary than traditional Medicare, and often wrongfully
deny care.

What’s more, federal audits have found Medicare Advantage plans systematically overbilling
the public — mostly by billing as if patients are sicker than they really are, a scheme known as “upcoding.” Officials estimate the private plans collected $650 million in overpayments from 2011 to 2013.

 
 

Listen to reporter Andrew Perez discuss this article.

The Biden administration is expected to finalize a rule next month to try to recoup some of these overpayments — but Medicare Advantage insurers are threatening to sue if the rule moves forward as written, according to Stat News. If insurers sue, it could further delay the government’s efforts to claw back excess payments stretching back more than a decade, as well as future overpayments.

The health insurance industry argues that regulators should allow for some level of payment errors — and should only apply new rules to audits moving forward, instead of retroactively punishing past misconduct.

“It’s crazy,” said Diane Archer, founder of Just Care USA, an organization that opposes Medicare privatization. “They overcharged. Who’s ever heard of a situation where you’re overcharged and you don’t get your money back? It’s beyond comprehension. The Medicare trust fund should not be paying out funds inappropriately, and it’s driving up Medicare [insurance] premiums.”

Tip Jar

“Hundreds Of Millions Of Dollars, If Not More, At Stake”

President Joe Biden is doing nothing to slow the Medicare privatization push. Indeed, his administration has hiked payments to Medicare Advantage insurers while expanding a program called ACO REACH that allows companies to enroll seniors on traditional Medicare into private health care plans without their informed consent.

But in a significant shift, last month the Biden administration proposed new regulations to prevent Medicare Advantage insurers from wrongfully denying claims or refusing to approve services that would be paid under the traditional public Medicare program.

Consumer advocates like David Lipschutz, associate director of the Center for Medicare Advocacy, were pleasantly surprised by the proposal — even if it came a decade late.

Lipschutz noted that the industry response to the proposed claim denial regulations has been “been pretty muted so far.”

He said insurers are far more concerned about two planned announcements from the Centers for Medicare and Medicaid Services next month that could have much greater impact on their bottom line.

“There are potentially hundreds of millions of dollars, if not more, at stake,” said Lipschutz.

Regulators could decide whether to factor insurers’ upcoding tactics into how much they pay Medicare Advantage plans. They are also expected to announce a final audit rule to prevent future overpayments and recoup some of the cost of excessive disbursements that have gone to Medicare Advantage insurers in the past.

Speaking at the annual J.P. Morgan Healthcare Conference this week, Humana’s chief financial officer, Susan Diamond, said “the industry likely will go to litigation” if the final audit rule does not include a so-called fee-for-service adjuster. Such a provision would allow insurers to get away with some level of diagnosis coding and billing errors — and it would likely substantially reduce the sums that insurers would have to pay back to the government.

The dollars at stake are significant. In September, the office of the inspector general at the Health and Human Services Department (HHS) released audit
reports finding that even just the Medicare Advantage plans affiliated with Humana owed the government nearly $44 million worth of overpayments from 2016 and 2017.

A separate HHS inspector general audit
found a Florida Humana plan overcharged Medicare by nearly $200 million in 2015.

“Prospectively, Not Retroactively”

Medicare Advantage has become a major profit-driver for the insurance industry, with government funds now accounting for a majority of most big insurers’ health plan revenues.

That’s especially true for Humana, which received more than 90 percent of its health plan revenue from taxpayers in 2021. UnitedHealth Group and CVS Health, which owns Aetna, both brought in more than 70 percent of their health plan revenue from the government.

Those insurers are part of the Better Medicare Alliance, a health insurance industry front group that spent nearly $3 million on TV ads promoting Medicare Advantage between Election Day and the end of the year, according to data from AdImpact.

 
 

The Better Medicare Alliance has called on the government to audit every Medicare Advantage plan annually “to increase program oversight and ensure that arbitrary decisions about which contracts are audited do not disproportionately impact some organizations more than others.”

The group has additionally argued that “changes to audit methodologies should be applied prospectively, not retroactively,” because doing the former “would invalidate actuarial assumptions made by health plans over more than a decade and threaten the care that seniors rely on today.”

Having the audit rule changes apply prospectively would allow insurers to retain years of overpayments.

Lipschutz said that the Better Medicare Alliance “and the folks that fund them don’t want to pay out what could be owed to the program looking backwards, so they want to try to focus on moving forward.”

While the Better Medicare Alliance does not disclose its donors, CVS Health reported donating $3 million to the group in 2021. Humana gave $2
million that year and $1 million in the first half of 2022.

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Executives from CVS Health, Humana, and UnitedHealth Group serve on the alliance’s board of directors. (UnitedHealth Group does not voluntarily disclose its donations to dark money front groups like the Better Medicare Alliance.)

Humana and CVS Health also belong to America’s Health Insurance Plans (AHIP), the powerful D.C. health insurance industry lobby.

Last summer, AHIP submitted a comment letter opposing the Medicare Advantage audit rule, arguing it “fails to account for errors in [fee-for-service] Medicare data” and complaining that it would apply retroactively.

Retroactive rulemaking is unfair, inappropriate, and legally impermissible,” wrote AHIP.

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FWA- Birmingham company to pay $153,300 on false Medicaid claim allegations

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A software design error caused Connecticut to overbill for ABA services.

 
 

Clipped from: https://www.al.com/business/2023/01/birmingham-company-to-pay-153300-on-false-medicaid-claim-allegations.html

Birmingham-based Amvik Solutions is paying $153,300 to resolve allegations that it submitted false claims for payment to Connecticut’s Medicaid program, federal officials announced today.

Federal officials announced the civil settlement with the government, which resolves allegations under the federal False Claims Act. The case involved the Justice Department, the Department of Health and Human Services and the Federal Bureau of Investigation.

Amvik Solutions offers billing, claims and collection services for healthcare providers throughout the U.S., using its proprietary WebABA software.

According to the DOJ, Amvik was hired to handle billing and claims for Helping Hands Academy, a Bridgeport, Conn. services provider working with children with autism.

The government alleges that when submitting claims for payment to Connecticut Medicaid on behalf of Helping Hands, Amvik falsely identified the incorrect Board Certified Behavior Analyst (“BCBA”) as the rendering provider on the claims.

This caused Connecticut Medicaid to pay claims that it would not have otherwise paid, investigators said. The action took place from Oct. 3, 2019 to Oct. 1, 2020.

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FWA- Healthcare billing fraud: 13 recent cases

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A nice little round-up of Medicaid fraud.

 
 

Clipped from: https://www.beckershospitalreview.com/legal-regulatory-issues/healthcare-billing-fraud-13-recent-cases.html

From a Florida physician getting 20 years in prison for the “largest ever” case of its kind, to a New York gastroenterologist getting 30 months in prison for a Medicare fraud scheme, here are 13 healthcare billing fraud cases Becker’s has reported since Dec. 29. 

1. Medical billing company settles false claims allegations

Birmingham, Ala.-based medical billing company Amvik has agreed to pay $153,300 to settle allegations that it submitted false claims to the Connecticut Medicaid program for applied behavior analysis services. 

2. North Carolina lab owner convicted in $11M Medicaid fraud scheme

North Carolina lab owner Donald Booker was convicted for his role in a scheme to defraud the state’s Medicaid program with medically unnecessary urine tests. 

3. Mississippi provider pays $1.8M to settle overbilling allegations

A Mississippi orthopedic clinic and its owner, Hanna “Johnny” Mitias, MD, agreed to pay $1.8 million to settle allegations he overbilled Medicare and Medicaid for viscosupplementation agents.

4. 3 companies settle for $745K for misbranded migraine devices

Medical device distributor Jet Medical and two related companies agreed to pay $745,000 for allegedly instructing, coaching and encouraging medical providers to submit improper billing codes to Medicare for services involving migraine headache devices not approved by the FDA. 

5. Lab owner wanted for alleged Medicare cancer testing scam

Khalid Satary, the owner of several labs in Georgia, Oklahoma and Louisiana, is a wanted fugitive for alleged fraud involving unnecessary cancer genetic testing that resulted in billing Medicare for more than $547 million. After failing to appear at a Dec. 12 court date, Mr. Satary was declared a fugitive of justice and is believed to be in Dubai.

6. Georgia physician to pay $1.85M to settle false claim allegations

Conyers, Ga., physician Aarti Pandya, MD, has agreed to pay $1.85 million to resolve allegations that she knowingly submitted false claims to Medicare, including for cataract surgeries and diagnostic tests that were not medically necessary, tests that were incomplete or of worthless value, and office visits that did not provide the level of service claimed.

7. Former Florida physician gets 20 years prison in ‘largest-ever’ case of its kind

Former Florida physician Michael Ligotti, DO, was sentenced to 20 years in prison and ordered to surrender his medical license after pleading guilty to an addiction fraud treatment scheme that accounted for more than $746 million in billings to federal and private insurers and about $127 million in reimbursements. 

8. Texas lab owners charged in $107M Medicare fraud scheme

The owners of the Lewisville, Texas-based Trinity Clinic are accused of allegedly acquiring thousands of Medicare beneficiaries DNA specimens and corresponding prescriptions that the laboratory used to fraudulently bill the Medicare and Medicare Advantage for genetic testing. The men allegedly concealed the kickbacks through sham contracts for marketing and other services.

9. South Carolina man sentenced to 7 years in prison for stealing providers’ identities, Medicaid fraud

Jonathan Sumter, owner of PHC Supportive Services — a company that purported to provide behavioral healthcare to disabled, low-income individuals — was sentenced to more than seven years in federal prison for stealing the identities of providers and Medicaid recipients and billing South Carolina Medicaid for more than $1 million in false claims.

10. Arkansas cardiologist pays $900K to settle Medicare fraud allegations

Hot Springs, Ark.-based cardiologist Jeffrey Tauth, MD, agreed to pay more than $900,000 to settle allegations he submitted claims to Medicare for medically unnecessary placement of cardiac stents. 

11. New York physician gets 30 months in prison for Medicare fraud

New York gastroenterologist Morris Barnard, MD, was sentenced to 30 months in prison for billing Medicare more than $3 million for colonoscopies and other procedures that were not performed. 

12. Cardiologist pays $931K to settle lab test kickback allegations

Kentucky cardiologist Dr. Kishor Vora paid $931,500 to settle allegations he took kickbacks from a testing lab. 

13. Louisiana physician pleads guilty to Medicare fraud scheme

East Baton Rouge, La.-based physician Robert Dean, MD, pleaded guilty to his role in a $1.3 million Medicare fraud scheme in which he allegedly falsified medical orders for knee braces, claiming he examined and performed tests on patients he never met face to face. 

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FWA- $6.2 million in benefit overpayments recovered during first quarter of fiscal year

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Don’t let anyone tell you member fraud is not real. This article is about $6.2M in recoveries (so probably 10x that in losses) for just one quarter.

 
 

Clipped from: https://oig.hhs.texas.gov/about-us/news/62-million-benefit-overpayments-recovered-during-first-quarter-fiscal-year

The OIG’s Benefits Program Integrity (BPI) unit completed 3,205 investigations involving some form of benefit recipient overpayment or fraud allegation in the first quarter of fiscal year 2023. These efforts led to $6,255,879 in recoveries, 5 cases referred for prosecution and 187 cases referred for administrative disqualification.

Most completed investigations involved applicants misrepresenting the number of income-earning household members. Programs like the Supplemental Nutrition Assistance Program (SNAP), Medicaid and others use household composition and income to determine a client’s eligibility for assistance and the proper benefit amount. Below is a selection of SNAP fraud cases involving program clients.

Dallas SNAP client pleads guilty to fraud

In September, a Dallas woman pleaded guilty in Texas District Court on charges of illegal possession of Supplemental Nutritional Assistance Program (SNAP) benefits. The charges stemmed from an investigation by the OIG.

The 1996 Federal Welfare Reform Act requires states to permanently disqualify individuals from the SNAP program if they have a felony drug conviction for conduct occurring after August 22, 1996. Applicants must provide truthful information to the state and notify the State of any past felony drug convictions during the application process.

The individual in question applied for SNAP benefits on January 31, 2011, and claimed under penalty of perjury that she had no such felony drug convictions. However, OIG investigators uncovered evidence that she was convicted of Unlawful Possession of a Controlled Substance, a state jail felony, on April 15, 2004.

The investigation showed that from January 2011 through November 2012, the defendant failed to disclose the conviction on five separate applications for SNAP benefits, receiving $9,252 in excess benefits. As a result, she was sentenced to three days in county jail and permanently disqualified from the SNAP program.

Olney woman convicted for SNAP fraud

A woman in Olney was found guilty in an administrative hearing of committing an Intentional Program Violation. The verdict is the result of an investigation by the OIG.

The individual applied to receive SNAP benefits on October 20, 2017. Because eligibility is tied to household resources, applicants must provide truthful information to the state and notify the state if their household’s composition or income changes.

In her application, the defendant claimed under penalty of perjury that the household consisted of only herself and two children. However, OIG investigators uncovered evidence that the children’s father was, in fact, living in the home and receiving income from a full-time job.

The investigation revealed that over more than four years, the perpetrator received $21,148 in excess benefits because of the fraudulent, unreported information. As a result, she was disqualified from the SNAP program for 12 months and ordered to pay full restitution.

Hidalgo County SNAP and Medicaid client pleads guilty to theft

A Hidalgo County resident pleaded guilty to felony theft after an investigation by the OIG.

The individual applied to receive SNAP benefits on August 19, 2015. In her application, the defendant claimed that the household’s income was from her employment. However, OIG investigators found that the defendant had consistent U.S. currency deposits into her and her husband’s joint bank account that she did not report during the application process. Had she truthfully disclosed the household income, her benefits would have been drastically reduced since household resources determine eligibility.

The defendant continued to falsely report the household income for almost four years, from August 2015 through May 2019. In total, the defendant obtained $20,397 in SNAP benefits and $11,514 in Medicaid benefits she was not entitled to receive.

In September 2022, she was sentenced to 10 years of probation and ordered to pay $31,911 in restitution to Texas Health and Human Services.