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Growing health care fraud drastically affects all of us

SEPTEMBER/OCTOBER 2012
BY LAUREN E. DAVIS, CFE, ASA
Source: Association of Certified Fraud Examiners

Rx for Fraud: Health care fraud issues

Welcome to the new health care fraud column. In May, U.S. authorities charged 107 people — including doctors, nurses and other licensed medical professionals, for allegedly trying to defraud Medicare of about $452 million, the largest Medicare fraud sweep to date. “Health care fraud shows no sign of abating,” said Dr. Joseph T. Wells, CFE, CPA, founder and Chairman of the ACFE, during his recent keynote message at the 23rd Annual ACFE Fraud Conference & Exhibition. “Don’t expect a downturn any time soon because governments have a long history of being able to dole out money without keeping very good track of it.”

In this inaugural column, Lauren E. Davis, CFE, ASA, a consulting manager with Pershing Yoakley & Associates, P.C., describes other recent cases, pertinent U.S. legislation and governing agencies, typical schemes and ways to detect and deter health care fraud. — ed.

SeptOct-healthcare-costs.jpg 
BARIS SIMSEK/ISTOCKPHOTO 
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Health care fraud is a serious problem affecting every patient and consumer. The devastating situation is rooted not only in the excessive financial losses incurred, which extend into the billions of dollars every year, but also in patient harm. It’s estimated that the economic cost of fraud related to health care in the U.S. is 3 percent to 10 percent of all healthcare spending — an estimated $68 billion to $260 billion annually.  

Fraudsters commit a wide variety of schemes against private and public insurance companies by filing fictitious health care claims to generate profits. As health care costs rise, so will the costs associated with these schemes. Consumers then will endure rising insurance premiums and out-of-pocket expenses.

RECENT HEALTH CARE FRAUD INDICTMENTS

The successful prosecution of individuals charged with committing health care fraud is an essential step in the deterrence of fraudulent activity. The punishment of health care fraud perpetrators can include such serious consequences as fines, incarceration and even the loss of the provider’s right to practice in the medical profession. The following are examples of recent fraud indictments:

Medicare Fraudulent Billing Scheme — Justice News, June 2012 
Various individuals, including owners, the CEO and other senior employees, of American Therapeutic Corporation (ATC), a mental health company in Miami, have been convicted or named as defendants for their participation in a $205 million Medicare fraud scheme involving fraudulent billings. The defendants are alleged to have billed Medicare for hundreds of millions of dollars for services that were either unnecessary or never provided to the patients, and based on fraudulent documentation. Some key participants — ATC’s executives, Lawrence Duran, Marianella Valera, Judith Negron, and Margarita Acevado — were sentenced to 50 years, 35 years, 35 years and 91 months in prison, respectively, for their roles in the fraud scheme. 

Settlement of False Claims Act allegations — Justice News, December 2010
Detroit Medical Center, a non-profit company that owns and operates hospitals and outpatient facilities in Detroit, allegedly engaged in improper financial relationships with referring physicians. The company has agreed to pay $30 million to settle allegations that it violated the False Claims Act, the Anti-Kickback Statute and the Stark Statute. 

Medicare fraud scheme — Justice News, December 2010
The owner and vice president of Wayne County Therapeutic Inc. were sentenced to 151 months and 108 months in prison, respectively, and ordered to pay $6.5 million in restitution. The two were the leaders in a $23 million Medicare fraud scheme, which included the filing of false claims for physical and occupational therapy services that were never provided

Medicare and Private Insurance Fraud Scheme — Justice News, June 2012
Boris Sachakov, M.D., owner and operator of Colon and Rectal Care of New York, P.C., was found guilty on one count of health care fraud and five counts of health care false statements. The indictment alleged that Sachakov submitted more than $22.6 million in false and fraudulent claims to Medicare and private insurance companies for surgeries and medical services that were never provided and received in excess of $9 million on those claims. Sachakov faces a maximum penalty of 35 years in prison and an $18 million fine. 

Organized crime health care fraud — Justice News, October 2010
A total of 73 defendants, including alleged members and associates of an organized crime enterprise, were indicted for various fraudulent billing schemes totaling approximately $163 million. The frauds committed included submission of bills for medically unnecessary treatments or for treatments that were never provided, identity theft of physicians and Medicare beneficiaries and the operation of phony clinics for the purpose of submitting Medicare reimbursement claims. 

Would you recognize health care fraud of you saw it? Financial gain is often the reason behind most health care fraud? What other reasons are there? Why? Why not?

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FDA and NIH let clinical trial sponsors keep results secret and break the law

DAVIDE BONAZZI/SALZMAN ART

Source: Science Magazine
By Charles PillerJan. 13, 2020 , 11:00 AM

For 20 years, the U.S. government has urged companies, universities, and other institutions that conduct clinical trials to record their results in a federal database, so doctors and patients can see whether new treatments are safe and effective. Few trial sponsors have consistently done so, even after a 2007 law made posting mandatory for many trials registered in the database. In 2017, the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) tried again, enacting a long-awaited “final rule” to clarify the law’s expectations and penalties for failing to disclose trial results. The rule took full effect 2 years ago, on 18 January 2018, giving trial sponsors ample time to comply. But a Science investigation shows that many still ignore the requirement, while federal officials do little or nothing to enforce the law.

Science examined more than 4700 trials whose results should have been posted on the NIH website ClinicalTrials.gov under the 2017 rule. Reporting rates by most large pharmaceutical companies and some universities have improved sharply, but performance by many other trial sponsors—including, ironically, NIH itself—was lackluster. Those sponsors, typically either the institution conducting a trial or its funder, must deposit results and other data within 1 year of completing a trial. But of 184 sponsor organizations with at least five trials due as of 25 September 2019, 30 companies, universities, or medical centers never met a single deadline. As of that date, those habitual violators had failed to report any results for 67% of their trials and averaged 268 days late for those and all trials that missed their deadlines. They included such eminent institutions as the Harvard University–affiliated Boston Children’s Hospital, the University of Minnesota, and Baylor College of Medicine—all among the top 50 recipients of NIH grants in 2019.

The violations cover trials in virtually all fields of medicine, and the missing or late results offer potentially vital information for the most desperate patients. For example, in one long-overdue trial, researchers compared the efficacy of different chemotherapy regimens in 200 patients with advanced lymphoma; another—nearly 2 years late—tests immunotherapy against conventional chemotherapy in about 600 people with late-stage lung cancer.

Other leading NIH grantees did only slightly better in Science’s analysis based on data collected from the TrialsTracker website of the University of Oxford, which automatically mines information from ClinicalTrials.gov. The University of Texas MD Anderson Cancer Center and the Mayo Clinic both failed to report results on time, or at all, in about two-thirds of their trials. Yale University failed to do so in 84% of its trials. NIH’s own institutes also had a bad record. They are directly responsible for reporting results when they sponsor studies done by agency staff or some grantees, and the top four NIH institute sponsors, taken together, reported results late or not at all in more than six of every 10 trials Science looked at.

Contacted for comment, none of the institutions disputed the findings of this investigation. In all 4768 trials Science checked, sponsors violated the reporting law more than 55% of the time. And in hundreds of cases where the sponsors got credit for reporting trial results, they have yet to be publicly posted because of quality lapses flagged by ClinicalTrials.gov staff (see sidebar).

Although the 2017 rule, and officials’ statements at the time, promised aggressive enforcement and stiff penalties, neither NIH nor FDA has cracked down. FDA now says it won’t brandish its big stick—penalties of up to $12,103 a day for failing to report a trial’s results—until after the agency issues further “guidance” on how it will exercise that power. It has not set a date. NIH said at a 2016 briefing on the final rule that it would cut off grants to those who ignore the trial reporting requirements, as authorized in the 2007 law, but so far has not done so.

Missed deadlines

Among more than 4700 clinical trials examined by Science, less than 45% had their results reported early or on time to ClinicalTrials.gov.150631.6%Not reported113223.7%213044.7%Reported ontime or earlyReported late(GRAPHIC) N. DESAI/SCIENCE; (DATA) CLINICALTRIALS.GOV, VIA TRIALSTRACKER

Many scientists who conduct clinical trials, and their sponsors or funders, have downplayed concerns about late or missing results in ClinicalTrials.gov. Researchers, doctors, and patients can instead learn about trial outcomes from peer-reviewed publications, they say. But thousands of trials are never published, particularly when they find treatments ineffective, history has shown. ClinicalTrials.gov also uses a common format, allowing relatively easy comparisons of results across trials that journal articles rarely make possible. Doctors, researchers, and potential trial participants rely on the site, to judge from its 215 million monthly page views.

Deborah Zarin, a physician at Brigham and Women’s Hospital and Harvard who headed ClinicalTrials.gov between 2005 and 2018, says the Science findings show failures of the research culture, FDA, and NIH. “If this was a priority for the leadership of NIH, then they could ensure that high-quality, timely reporting happened all of the time,” says Zarin, an NIH-paid research consultant for the database. “You can set up processes so trial reporting is an expectation. You can’t pass ‘go’ and collect $200 until this is done.”

Zarin, who works in a program to advance clinical research, adds that the problem persists because “reporting to ClinicalTrials.gov is frequently seen by sponsors, funders, and trialists as an annoying administrative and perhaps legal burden, not a scientific imperative. Human nature being what it is, people follow the requirements when forced to do so.”

NIH and FDA officials do not seem inclined to apply that pressure. Lyric Jorgenson, NIH deputy director for science policy, says her agency has been “trying to change the culture of how clinical trial results are reported and disseminated; not so much on the ‘aha, we caught you,’ as much as getting people to understand the value, and making it as easy as possible to share and disseminate results.” To that end, she says, ClinicalTrials.gov staff have educated researchers about the website and improved its usability.

As for FDA, Patrick McNeilly, an official at the agency who handles trial enforcement matters, recently told an industry conference session on ClinicalTrials.gov that “FDA has limited resources, and we encourage voluntary compliance.” He said the agency also reviews reporting of information on ClinicalTrials.gov as part of inspections of trial sites, or when it receives complaints.

McNeilly declined an interview request, but at the conference he discounted violations of ClinicalTrials.gov reporting requirements found by journalists and watchdog groups. “We’re not going to blanketly accept an entire list of trials that people say are noncompliant,” he said. Such determinations require “nonpublic information” submitted to the agency by trial sponsors. In response to Science’s findings, a spokesperson said an absence of posted results on ClinicalTrials.gov did not mean a trial sponsor has broken the 2007 law.

Yet that law and the 2017 final rule detail only a few exemptions that would allow trial sponsors to withhold results on the basis of nonpublic information. The very few registered trials that qualify for those exemptions are not flagged as violators by TrialsTracker or in Science’s analysis.

CONGRESS APPROVED THE CREATION OF ClinicalTrials.gov in 1997, after allegations that patients were harmed because companies withheld evidence showing their medicines were ineffective or hazardous. A widely cited case involved the GlaxoSmithKline antidepressant Paxil (paroxetine). According to legal filings and a report in The BMJ, the firm held secret data showing that in clinical trials the drug was ineffective and caused suicidal thoughts in teenagers, yet encouraged doctors to prescribe it for young people.

Registration was only required initially for trials of treatments for serious or life-threatening diseases. But the 2007 law, the Food and Drug Administration Amendments Act, required sponsors to register a much broader range of trials within 21 days of enrolling the first patient, and to post summary results, adverse events, and other data to ClinicalTrials.gov within 1 year of collecting the last patient data. Although many trials, such as industry-sponsored early-stage evaluations of drug safety, are exempt from reporting, about 326,000 have been registered, and results have been posted for more than 40,000.

Yet until 2015, even the most active investigators at clinical research institutions treated the law more as a suggestion—not surprising given that the government enforced no penalties and did not publicly identify violators. A report on the news website STAT by this author and Talia Bronshtein first drew significant attention to specific trial sponsors—companies, government agencies, universities, and individuals—that routinely ignored reporting requirements. It sparked immediate improvement, according to NIH. (Those same authors documented some of that improvement in a 2018 STAT article.)

At a 2016 press briefing, NIH and FDA rolled out the final rule, aimed at boosting even greater compliance with the 2007 law. It took effect in January 2017, with first deadlines for results, and ostensibly enforcement, 1 year later. Then–FDA Commissioner Robert Califf said it would thereafter “be pretty hard to hide that you are doing a clinical trial or hide the result.” FDA, he vowed, was finally prepared, if necessary, to enforce the daily $10,000 penalty for noncompliance allowed under the law. (Adjusted for inflation, that figure recently rose above $12,000.)

“I don’t think anybody wants to be on the wall of shame,” NIH Director Francis Collins said at the press event, promising that NIH would publicly flag reporting violations on ClinicalTrials.gov itself.

“We are serious about this,” Collins said, threatening for the first time to enforce provisions of the 2007 law that allow NIH to rescind funding to grantees who violate the statute. “It’s hard to herd cats, but you can … take their food away,” he said. “This is about maintaining the trust that we have with participants in clinical trials. … If we fail to live up to that expectation, then that is an ethical failure.”

Three years later, TrialsTracker conservatively estimates that FDA could have collected more than $6 billion in ClinicalTrials.gov penalties so far. The agency has yet to demand a single dollar. And despite more than 2600 trials for which results are overdue or were filed late, NIH has yet to withhold a single grant as a result or post a single violation notice on ClinicalTrials.gov. No “wall of shame” exists.

“Public-facing websites run by the government should be accurate. That’s not asking much,” Senator Chuck Grassley (R–IA), who advocated for the 2007 law, wrote in an email after reviewing a summary of the Science findings. “It’s a question of basic management and agency competence. The government has a duty to police its work product, especially because the public trusts .gov websites will be accurate and reliable.”

To physician Ben Goldacre, who directs the Oxford program behind TrialsTracker, “The lack of urgency is really troubling.”

Why do you think so few clinical trail results and information is not submitted? What is the cost to taxpayers, patients and the community? Why? Do you trust this process?

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A dent to Feres: Troops to be able to file claims — but not sue — for medical malpractice

Pentagon & Congress

Source: Military Times
Photos Source: Military Times
Patricia Kime, December 11, 2019

Medical staff at David Grant USAF Medical Center perform surgery to a lung cancer patient Feb. 26, 2019, at Travis Air Force Base, Calif. Members of the military may soon be able to file claims for cases of negligence or malpractice in military health facilities. (Heide Couch/Air Force)

A provision in the fiscal 2020 National Defense Authorization Act will allow active-duty military personnel or their surviving families to seek compensation for personal injury or death caused by malpractice by military doctors or dentists.

But the proposal stops short of letting service members sue the federal government in malpractice tort claims, a legislative compromise that has some legal scholars declaring victory, while others question how the new process will work.

The bill, which passed the House today and is expected to move through the Senate later in the week, would let active-duty victims or survivors file a claim with the Defense Department for cases of medical negligence or malpractice by military health providers in medical facilities outside combat zones.

If the claim is substantiated by the Department of Defense and determined to deserve less than $100,000, DoD would pay the claim directly to the member or beneficiary. If the defense secretary decides that a sum larger than $100,000 is warranted, the claim would be forwarded to the Treasury Department for payment.

Victims would have two years after the malpractice incident or omission to file a claim, with the exception of the first year of the legislation’s enactment. Those seeking redress in 2020 would be able to file claims for cases dating to 2017.

If the bill is signed into law by President Donald Trump, it will be the first time in nearly 70 years an active-duty service member or their survivor would have redress in such claims.

Until now, the 1950 U.S. Supreme Court decision Feres v. the United States has kept troops from suing the federal government for injuries deemed incidental to military service, including medical malpractice.

The new legislation does not overturn Feres, but Rep. Jackie Speier, the California Democrat who championed the effort to change the law, called the provision’s inclusion a “landmark day in the fight for justice.”

“Service members and their families finally have a path forward in seeking compensation for medical malpractice committed by military health care providers, and the Defense Department will have to take their claims seriously,” Speier said.

Earlier this year, Speier introduced the Sgt. First Class Richard Stayskal Military Medical Accountability Act, which sought to allow troops to sue the government for damages in malpractice cases.

The bill was named for a former Marine and Army Special Operations soldier whose military health providers failed to see a 3-centimeter mass in one of his lungs on a pre-training CT scan. After repeatedly going to military physicians after the scan with health problems and told he had asthma or pneumonia, Stayskal found out from a civilian pulmonologist, that he actually had Stage 4 lung cancer.

Before and after photos of 1st Lt. Katie Blanchard, who was set on fire by a civilian Army employee in 2016. (Facebook)
She was set on fire by a civilian hospital employee. Now this soldier is claiming damages against the Army.

An Army nurse set on fire by a civilian hospital employee two years ago has filed a personal injury claim against Fort Leavenworth.Meghann Myers

Despite battling the terminal disease, Stayskal hired an attorney, Natalie Khawam of the Whistleblower Law Firm in Tampa, and pursued his case in Congress, arguing that Feres was outdated and unfair when applied to military medical malpractice.

Speier said Tuesday the provision would not have gone forward if it hadn’t been for Stayskal, who knocked on nearly every door in the House and Senate.

“Today belongs to … Stayskal, who … forged a bipartisan coalition to achieve this legislative breakthrough through his countless visits to D.C. and heroic advocacy,” Speier said.

Khawam said she and Stayskal plan to travel to D.C. this week to watch the Senate vote. She said they are thrilled that a workaround was found in the face of opposition from some lawmakers, including Sen. Lindsey Graham, R-S.C., a former Air National Guard judge advocate general who has repeatedly advocated for preservation of the Feres ruling.

The proposed bill specifically states that it “does not change or repeal the Feres Doctrine,” but Khawam argued that the “reality is we have just changed history and changed the law to allow the military to not be barred by Feres.”

“We are providing legal recourse and compensation. The means may be different. But it’s the same end result, just a different means of accessing it,” Khawam said. “I actually am really impressed that they created this. It’s brilliant. This is saying, ‘Hey to all those haters who didn’t want to change Feres and repress our service members: here’s to you. We figured out a way around your motives and your issues.’ ”

But Speier has called the fix “far from perfect.”

She said Tuesday she has “serious concerns” that under the law, the Defense Department will run the claims process. She still believes service members deserve their day in federal court, the same as military family members, federal civilian employees and federal prisoners.

“I will continue to work to address the myriad injustices that remain due to the Feres Doctrine,” Speier said.

Earlier this year, Paul Figley, professor of legal rhetoric at American University’s Washington College of Law, testified before the House in support of Feres in medical malpractice, noting long-standing government concerns that overturning the law could result in different monetary values placed on service members’ deaths or dismemberment.

DoD, also has an established compensation system for such cases, Figley argued.

On Tuesday, Figley told Military Times that the compromise in the pending bill is a “much, much better bill” than the original proposed Stayskal legislation, but it has problems. First, claims will be handled using “uniformed standards consistent with the generally accepted standards uses in a majority of states,” yet states laws vary so widely, determining what this means puts a burden on the Defense Department, he said.

Second, unlike similar claims filed in the State Department, DoD malpractice claims will not go to the Department of Justice for consideration before going to Treasury — a step that could help determine the appropriate amount to be awarded in a case.

“If the appropriate officer in the Secretary of Defense Office determines an amount to be paid is meritorious, they are going to shoot it straight to Treasury. This is really not in the competency of the SecDef’s office. How many wrongful death claims do they see?” Figley asked.

Finally, it will create a different value system for service members’ death or dismemberment based on circumstance.

“This will be an issue because this is going to get people who lose a leg because of malpractice a lot more money than a person who lost their leg because it got shot off or was injured in a truck wreck,” Figley noted.

The new legislation fails to account for all the egregious cases that came before 2017, including those rejected in the past decade by the U.S. Supreme Court, such as the tragic case of Air Force Staff Sgt. Dean Witt, who suffered severe brain damage during a botched routine appendectomy.

Witt was left in a vegetative state before he died three months later.

Or the case of Navy Lt. Rebekah “Moani” Daniel, whose death at a Navy hospital in Bremerton, Washington, following the birth of her first child in 2014 was attributed to an inadequate response by providers to postpartum hemorrhaging.

She bled to death without ever having held her newborn daughter.

Earlier this year, the Supreme Court justices rejected the Daniel case. But unlike previous cases the justices had refused without comment, Justice Ruth Bader Ginsburg wrote that she would support granting the Daniel petition, while Justice Clarence Thomas wrote a dissent to the petition’s denial.

“Such unfortunate repercussions — denial of relief to military personnel and distortions of other areas of law to compensate — will continue to ripple through our jurisprudence as long as the Court refuses to reconsider Feres,” Thomas wrote.

Walter Daniel told Military Times Wednesday that the Supreme Court’s rejection of his wife’s case was a “tough outcome” and he still believes Feres should be overturned.

But, he added, the new legislation is a “step in the right direction.”

“Congress has recognized that not holding medical personnel accountable is a problem in the military health care system. The men and women of the armed forces deserve better protection for the sacrifices they make for America,” Daniel said.

In making his case for overturning Feres when it comes to military malpractice cases, University of San Diego School of Business professor Richard Custin, a long-time proponent for rejecting Feres for reasons beyond medical malpractice, cited the Daniel case.

“All sides of the political spectrum are interested in changing this. I mean, look, when you’ve got Thomas and Ginsburg lining up …” he said. “Lindsey Graham should be ashamed of his position because there is bipartisan support for rejecting Feres.”

He also said he finds it troublesome that as part of the claims process, the Defense Department will be “the negligent party, the judge and the jury” for deciding claims.

“We need a more comprehensive rejection of Feres,” he said.

The number of claims that might be filed a year is not known. According to the Defense Health Agency, the number of “sentinel events” — those resulting in death or serious injury, including loss of limb or function or a serious psychological injury — increased in military medical and dental facilities from 121 in 2013 to 319 in 2016.

How many of those involved active-duty patients was not disclosed.

In a 2018 report by the Government Accountability Office, DoD also conceded that its methods for tracking such adverse events and responding to them was unreliable.

The proposed defense policy act includes a provision that will require GAO to report on the number of physicians and other medical providers at DoD who lost their medical malpractice insurance before they were hired and study the outcomes of patients who have taken action against DoD for negligence or medical malpractice.

Khawam said that in addition to Stayskal’s claim, she has “at least another dozen” she plans to file for clients in 2020. But first, she said, she looks forward to “throwing a party for Richard,” who has responded well to an experimental treatment.

“I’m happy that our military will be provided for, compensated for, any kind of medical malpractice. They are victims too.” Khawam said.

How was this article helpful? What rights should service members have? Why? Why not? Thank you for your service, service members.

Share your comments with the community by posting them below. Share the wealth of health with your friends and family by sharing this article with 3 people today. As always you are the best part of what we do. Keep sharing!

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Virginia Beach Psychiatrist sentenced to prison for healthcare fraud scheme

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Source: 13 News Now
Feature Photo Source: Dimitri Houtteman


The scheme involved overbilling healthcare benefit programs by seeing patients for only five to 10 minutes but then billing them for 41 to 63 minutes on average.

VIRGINIA BEACH, Va. — A Virginia Beach doctor was sentenced on Thursday to over two years in prison for defrauding Medicare, Medicaid, and Tricare, and other health care benefits programs out of hundreds of thousands of dollars.

The Department of Justice said 64-year-old Udaya K. Shetty also agreed to pay over $1 million to settle related civil claims on top of the prison sentence.

According to court documents, Shetty was a licensed psychiatrist practicing medicine at his practice, Behavioral & Neuropsychiatric Group. Starting in 2013, he created a scheme where he could overbill healthcare benefit programs by seeing patients for only five to 10 minutes but then billing for services that were on average 41 to 63 minutes long.

Shetty instructed his staff to often double, triple, or even quadruple book appointment times. The fraud started to become apparent when investigators discovered that on dozens of instances Shetty would need more than 24 hours a day of working to perform the services for which he billed.

RELATED: Virginia doctor admits to writing fake prescriptions for black market

In 2017, Shetty closed his practice and joined another psychiatric practice, Quietly Radiant Psychiatric Services. While there, Shetty and one of his former employees, Mary Otto, engaged in a similar scheme. Although other Quietly Radiant staff members were responsible for billing, Shetty directed Otto to access the billing system and change all of his billing data to a higher billing rate.

Otto complied and changed the data without the knowledge of Quietly Radiant’s staff. As a result of their actions, Shetty and Otto defrauded various healthcare benefit programs of more than $450,000.

Otto pled guilty for her role in the scheme and was sentenced to 15 months in prison on January 10.

In regards to the civil settlement, Shetty agreed to pay $1,078,000 to the United States and the Commonwealth of Virginia to resolve his liability under the False Claims Act and the Virginia Fraud Against Taxpayers Act for submitting or causing the submission of false claims to the Medicare, Medicaid, and TRICARE programs.

Would you recognize health care fraud when you see it? What does it look like? What are the affects of health care fraud taxpayers, patients and the community?

Share your comments with the community by posting them below. Share the wealth of health with your friends and family by sharing this article with 3 people today. As always you are the best part of what we do. Keep sharing!

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Physician ordered to pay $9.5 million in restitution in home health fraud case

Shidonna Raven Garden and Cook

November 23, 2020
Joe Jancsurak
Feature Photo Source: Frank Busch Pzifgmbsxcc

A Texas physician has been sentenced to five years in prison and ordered to pay $9.5 million in restitution for her role in a multi-million Medicare fraud scheme, according to the Department of Justice.

Yolanda Hamilton, M.D., was convicted of making it appear that patients qualified and received home healthcare services, when often they did not. Others reportedly involved in the scheme allegedly paid patients to receive home healthcare services, which often were medically unnecessary, not provided, or both.  

The evidence, according to the Justice Department, also showed that Hamilton required home healthcare agencies to pay an illegal kickback, which the physician disguised as a co-pay, in exchange for her certifying and recertifying patients for home healthcare services. 

Hamilton was convicted of one count of conspiracy to commit healthcare fraud, one count of conspiracy to solicit and receive healthcare kickbacks, and two counts of false statements relating to healthcare matters.

Would you recognize health care fraud if you saw it? What would it look like? What should be done?

Share your comments with the community by posting them below. Share the wealth of health with your friends and family by sharing this article with 3 people today. As always you are the best part of what we do. Keep sharing!

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GP stalked patient after accessing her medical records to get phone number, tribunal hears

Shidonna Raven Garden and Cook

14 JANUARY 2019 • 12:25PM 

AGP was accused of stalking a patient after accessing her medical records so he could obtain her mobile phone number, a medical tribunal heard.

Dr Chika Mbah, 37, allegedly sent a stream of WhatsApp messages asking the woman out for a date and turned up once outside her home after signing her off work for work-related stress.

The woman repeatedly declined his invitation but father-of-two Mbah, who called himself ‘Dr Sandy’, kept calling her and left messages saying: “How are you stranger? – don’t you remember, it’s me, Dr Sandy?,’ the tribunal heard.

The patient, who was not named and known as Patient A, was grieving at the time Mbah contacted her following the death of her grandparent. 

She was said to be so uncomfortable as a result of his advances that she refused to attend his surgery for an urgent check up over a stomach problem.

Mbah was suspended from medical practice for three months after he was found guilty of misconduct when he admitted pursuing an improper relationship with the patient. 

But he denied allegations of illicitly accessing her medical records and the panel found no evidence of “any predatory behaviour”.

In a statement read out at the Medical Practitioners Tribunal Service in Manchester, the woman said: “During many messages, he asked me out for a drink which I did not go to and I received the odd phone call for a chat.

Health care fraud comes in many forms. Would you recognize it if you saw it? What does it look like? What are the costs?

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Patients voice concerns after Chesapeake doctor arrested for health care fraud

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Source: WAVY News 10 | 11-09
Featured Photo Source: Unsplash, Sharon Mccutcheon

CHESAPEAKE, Va. (WAVY) — A Chesapeake doctor was arrested on Friday for alleged health care fraud and false statements related to health care matters. Court documents say the Federal Bureau of Investigation started investigating 69-year-old Javaid Perwaiz in September 2018, when they received a tip from a hospital employee who suspected he was performing unnecessary surgeries on unsuspecting patients.

Would you recognize health care fraud if you saw it? Would you know if you were taking unnecessary medicine or had an unnecessary procedure? What would it look like?

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Psychiatrist Sentenced to Prison for Healthcare Fraud Scheme – Norfolk, VA

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FOR IMMEDIATE RELEASE Thursday, January 16, 2020

Source: US Department of Justice
NORFOLK, Va. – A Virginia Beach doctor was sentenced today to 27 months in prison for defrauding Medicare, Medicaid, and Tricare, and other health care benefits programs out of hundreds of thousands of dollars.

Additionally, Udaya K. Shetty, 64, agreed to pay over $1 million to settle related civil claims.

According to court documents, was a licensed psychiatrist practicing medicine at his own practice, Behavioral & Neuropsychiatric Group. Beginning in 2013, Shetty created a scheme by which he could overbill healthcare benefit programs by seeing patients for only five to 10 minutes, but then billing for services that were on average 41 to 63 minutes long. Shetty instructed his staff to often double, triple, or even quadruple book appointment times. The fraud became apparent when investigators discovered that on dozens of instances Shetty would need more than 24 hours a day of working to perform the services for which he billed. 

In 2017, Shetty closed his own practice and joined another psychiatric practice, Quietly Radiant Psychiatric Services. While there Shetty, and one of his former employees, Mary Otto, engaged in a similar scheme. Although other Quietly Radiant staff members were responsible for billing, Shetty directed Otto to access the billing system and change all of his billing data to a higher billing rate.  Otto complied and changed the data without the knowledge of Quietly Radiant’s staff. As a result of their actions, Shetty and Otto defrauded various healthcare benefit programs of more than $450,000. Otto pled guilty for her role in the scheme and was sentenced to 15 months in prison on January 10.

In regards to the civil settlement, Shetty agreed to pay $1,078,000 to the United States and the Commonwealth of Virginia to resolve his liability under the False Claims Act and the Virginia Fraud Against Taxpayers Act for submitting or causing the submission of false claims to the Medicare, Medicaid, and TRICARE programs.

G. Zachary Terwilliger, U.S. Attorney for the Eastern District of Virginia; Martin Culbreth, Special Agent in Charge of the FBI’s Norfolk Field Office; Robert E. Craig, Special Agent in Charge for the Defense Criminal Investigative Service’s (DCIS) Mid-Atlantic Field Office; Maureen R. Dixon, Special Agent in Charge of the Office of Inspector General for the U.S. Department of Health and Human Services (HHS); and Mark R. Herring, Attorney General of Virginia, made the announcement after sentencing by U.S. District Judge Rebecca Beach Smith. Assistant U.S. Attorney Joseph L. Kosky prosecuted the criminal case. Assistant U.S. Attorney Clare P. Wuerker handled the civil case.

A copy of this press release is located on the website of the U.S. Attorney’s Office for the Eastern District of Virginia. Related court documents and information are located on the website of the District Court for the Eastern District of Virginia or on PACER by searching for Case No. 2:19-cr-089.

Some patients often start off with private health care and end up with Medicaid, Medicare or Tricare because these government health insurance or more advantageous for those medical ‘professionals’ seeking to defraud patients and insurance providers. Would you recognize health care fraud if you see it? What does it look like? Have you been a victim of health care fraud?

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HHS Turning up the HEAT on Healthcare Fraud Charges

medical fraud shidonna raven garden and cook

Source: Policy Med

HEALTHCARE REFORMHHS-OIG By Thomas Sullivan Last Updated May 5, 2018

Since the health care reform debate began almost two years ago, the Obama Administration has identified fighting fraud committed against public health care programs as a top priority. Both the Recovery Act and Affordable Care Act include significant provisions to fight health care fraud. Among many other changes, the ACA amended the False Claims Act’s public disclosure provision and strengthened the provisions of the federal health care Anti-Kickback Statute.

One of the main reasons for this is because the Obama Administration largely asserted during the debate that significant reductions in health care fraud and abuse could help pay for part of the health care reform legislation.

These goals were further expressed in President Obama’s FY 2011 budget, which included $561 million in discretionary resources to the Department of Health and Human Services (HHS), an increase of $250 million. HHS Secretary Kathleen Sebelius acknowledged that this increase would strengthen the Medicare and Medicaid program integrity activities, with a particular emphasis on fighting health care fraud in the field, increasing Medicaid audits, and strengthening program oversight while reducing costs. 

Such an investment against fraud and abuse claims to help save $9.9 billion over ten years. According to HHS, the additional funding will better equip the Federal government to minimize inappropriate payments, pinpoint potential weaknesses in program integrity oversight, target emerging fraud schemes by provider and type of service, and establish safeguards to correct programmatic vulnerabilities.

Additionally, the HHS budget will install a set of new program integrity proposals that will give HHS the necessary tools to fight fraud by enhancing provider enrollment scrutiny, increasing claims oversight, improving Medicare’s data analysis capabilities, and reducing over-utilization of Medicaid prescription drugs. These proposals will claim to save approximately $14.7 billion over 10 years.

Consequently, the Department of Justice (DOJ) has been busy trying to reach that goal, securing more than $3 billion in civil settlements and judgments in cases involving fraud against the government in the fiscal year ending Sept. 30, 2010. Announcing this accomplishment, Tony West, Assistant Attorney General for the Civil Division, announced in a press release that this total includes $2.5 billion in health care fraud recoveries—the largest in history—and represents the second largest annual recovery of civil fraud claims.

West also mentioned that the amounts recovered under the False Claims Act since January 2009 have eclipsed any previous two-year period with $5.4 billion in taxpayer dollars returned to federal programs and the Treasury. Of that total, $4.6 billion were under the False Claims Act from health care providers and others in the industry, a two-year health care fraud record. DOJ also secured 25 criminal convictions. Since 1986, when Congress substantially strengthened the civil False Claims Act, recoveries now total more than $27 billion.RELATED POSTS

The largest fiscal year 2010 False Claims Act recoveries came from the pharmaceutical and medical device industries, which accounted for $1.6 billion in settlements, including the $669 million from Pfizer Inc., $302 million from AstraZeneca, and $192.7 from Novartis Pharmaceutical Corporation. These numbers may appear to be deceptive however, as some have predicted that the era of big pharma settlements may be ending. For example, many companies such as Pfizer have entered into lengthy corporate integrity agreements that span over the next several years.

While it is certainly important for revenue purposes that DOJ continues to successfully prosecute wrongful acts of companies, the agreements these companies have entered into require more of an oversight role than investigative, to ensure compliance with the agreement. Without large settlements, the DOJ might not be able to sustain its ‘profitability’ of fraud collections. For example, without a large settlement like Pfizer’s, DOJ’s claims may not cover the $500 million plus the government put in. In other words, if the administration is to continue such efforts, they will first have to recover $500 million to break even.

Much of the success for recovering this money stems from the Department of Health and Human Services (HHS) creation of a new interagency task force, the Health Care Fraud Prevention and Enforcement Action Team (HEAT). On May 20, 2009, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius created HEAT to increase coordination and optimize criminal and civil enforcement, which they argue results in higher quality health care at a more reasonable price. DOJ and HHS also assert that HEAT is used as a tool to protect the Medicare Trust Fund for seniors and the Medicaid program for the country’s neediest citizens.

West further acknowledged the role of HEAT by recognizing that Since January 2009, the Civil Division, together with the U.S. Attorneys’ offices, commenced more health care fraud investigations, secured larger fines and judgments, and recovered more taxpayer dollars lost to health care fraud than in any other two-year period.” Most of the cases resulting in recoveries were brought to the government by whistleblowers under the False Claims Act, the federal government’s primary weapon in the battle against fraud.

In 1986, Senator Charles Grassley and Representative Howard Berman led successful efforts in Congress to amend the False Claims Act to revise the statute’s qui tam (or whistleblower) provisions, which encourage whistleblowers to come forward with allegations of fraud. Since 1986, recoveries in qui tam cases have exceeded $18 billion, and relators (whistleblowers) have obtained more than $2.8 billion in awards. They were awarded $385 million in 2010.

Impact of Settlements

Ultimately, while the success of the DOJ is clear, how much this will continue down the road depends on a number of factors. Nevertheless, it is important that the DOJ and HHS continue to work with companies on solutions to prevent fraud, waste and abuse to reduce costs and improve efficiency in the health care system. While the recoveries may help to pay for some of the provisions in health care reform, it is more important that the companies maintain their trust and integrity with the public by adhering to their agreements and making a concerted effort to prevent fraud and abuse.

How much of your tax dollars do you think go towards health care fraud (unnecessary procedures, over billing etc.? How much of your health insurance premium dollars do you think goes towards paying for fraudulent procedures and over billing? Do you look at your insurance bill? Does your insurance company send you a copy of your medical charges?

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US coronavirus stimulus went to some healthcare providers facing criminal inquiries

Source: CNBC
PUBLISHED SAT, MAY 2 2020 6:07 AM EDT

The exterior of the U.S. Department of Health and Human Services in Washington, DC.

Eager to bolster the healthcare system during the coronavirus pandemic, the U.S. government last month sped $30 billion in stimulus payments to most healthcare providers that billed Medicare last year.

That speed resulted in taxpayers’ money flowing to some companies and people facing civil or criminal fraud investigations, according to defense lawyers and others representing more than a dozen firms and people facing such inquiries.

The disclosures about such payments have prompted outrage among some congressional Democrats, who say they highlight the problems with how stimulus funds have been distributed.

“I have an enormous amount of frustration with the way the Trump administration is distributing these dollars, and examples like these magnify the consequences of the White House’s efforts to limit transparency and stonewall oversight,” Senator Ron Wyden, ranking member of the Senate Finance Committee, told Reuters.

Henry Connelly, a spokesman for House of Representatives Speaker Nancy Pelosi, added: “It is alarming to see the Trump administration giving precious taxpayer dollars to unscrupulous entities while so many hospitals and health care workers on the frontlines of the battle against coronavirus are desperate for resources.”

The Department of Health and Human Services, which sent the payments, told Reuters it transmitted funds to all medical providers who submitted billings in 2019 to Medicare, the federal health insurance program for elderly and disabled Americans, unless they had already been excluded from participating.

It declined to respond to the criticism from Wyden and Pelosi’s office and did not respond to specific questions from Reuters about the payments.

Katherine Harris, a spokeswoman for the HHS Office of the Inspector General, said her office oversees the program but declined to comment on the specific distribution of funding.

“While we cannot comment specifically on any work other than what has been publicly announced, I can tell you that we regularly perform reviews of the department’s administration of programs, including the distribution of funding,” Harris said.

Reuters was unable to independently determine what portion of the stimulus payments went to entities and individuals involved in civil and criminal actions with Medicare.

In an email to funding recipients seen by Reuters, HHS asked providers to sign a lengthy attestation that stipulates they have been or will be treating patients suffering from COVID-19, the disease caused by the new coronavirus.

If providers do not respond within 30 days, HHS said it will assume they have accepted the government’s terms and conditions. It said in a statement it “has mechanisms in place to recoup funds and address fraudulent activity.”WATCH NOWVIDEO05:53CARES Act, Fed response insufficient given headwinds: Chief economist

The funds came from the $2.3 trillion CARES Act passed by Congress to blunt the economic toll of the pandemic, which has killed more than 64,000 Americans and thrown at least 30 million people out of work.

Unlike the portions of that package intended to help small businesses, which required companies to apply for it, some of the healthcare funding was initiated by the U.S. Department of Health and Human Services and showed up as a surprise in the bank accounts of many healthcare providers.

Reuters interviewed six defense lawyers and others representing more than a dozen healthcare providers facing civil or criminal inquiries who received the money, including a pain medicine doctor who recently settled a civil false claims case, and an operator of an assisted living facility who is planning to plead guilty to healthcare fraud.

“The left hand does not know what the right hand is doing,” said Joel Hirschhorn, an attorney who represents the pain medicine doctor and the operator of the assisted living facility.

The lawyers who spoke to Reuters declined to identify their specific clients, citing confidentiality rules.

The surprise deposit of funds has led attorneys to scramble to warn clients to be ready to return the money.

“There is no such thing as a windfall from the government,” said Sam J. Louis, a former prosecutor who is now a partner with the law firm Holland & Knight, whose law firm issued an alert to clients warning them of the potential of legal liability in taking the funds.

Some former federal prosecutors say it would not have been difficult for HHS to weed out these providers first.

“If fraudulent providers, either convicted or under investigation, are receiving CARES Act bail-outs automatically, without any vetting, then shame on the government,” said Paul Pelletier, one former prosecutor.

However, defense lawyers stressed that people charged with crimes are innocent until proven guilty, and they are not usually barred from billing Medicare until well after they are convicted of a crime. People facing criminal healthcare charges usually agree to stop billing Medicare as a condition of their bond, they added.

Another pool of practitioners eligible for the cash infusions include doctors who have lost their medical licenses or licenses to prescribe highly addictive drugs, said Ron Chapman, a lawyer in Miami.

HHS declined to say what portion of the $30 billion went to providers facing criminal or civil inquiries.

It said it distributed funds to more than 315,000 provider billing organizations reaching over 1.5 million healthcare providers.

In fiscal year 2019, investigations by the HHS inspector general’s office led to 747 criminal actions and 684 civil actions.

In the midst of the pandemic health care fraud is alive and prevalent while many suffer economically across the globe. How has the pandemic effected you financially? Do you think pandemic aid could have been better spent? How many people do you think lost or missed work? How many industries and small business have been impacted or closed due to COVID 19?

Share your comments with the community by posting them below. Share the wealth of health with your friends and family by sharing this article with 3 people today. As always you are the best part of what we do. Keep sharing!

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