Posts Tagged ‘fraud’
Law of Health Care Organization and Finance
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“There is something bad happening to our children in family courts today that is causing them more harm than drugs, more harm than crime and even more harm than child molestation”. – Judge Watson L. White, Superior Court Judge, Georgia “There is no system ever devised by mankind that is guaranteed to rip husband and wife or father, mother and child apart so bitterly than our present Family Court System.” – Judge Brian Lindsay, Retired Supreme Court Judge, New York Violations of Federal Law on Judicial Determinations: -Violation CFR Sec 1356.21(d): Documentation of Judicial Determinations (Must be supported by EXPLICIT evidence) (1) The judicial determinations regarding contrary to the welfare, reasonable efforts to prevent removal, and reasonable efforts to finalize the permanency plan in effect, including judicial determinations that reasonable efforts are not required, must be explicitly documented and must be made on a case-by-case basis and so stated in the court order. (2) Neither affidavits nor nunc pro tunc orders will be accepted as verification documentation in support of reasonable efforts and contrary to the welfare judicial determinations. (3) Court orders that reference State law to substantiate judicial determinations are NOT acceptable, even if State law provides that a removal must be based on a judicial determination that remaining in the home would be contrary to the child’s welfare or that removal can only be ordered after reasonable efforts have been …
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Charlotte woman indicted for health care fraud
CHARLOTTE, N.C. — Federal authorities say a woman is charged in a scheme to defraud Medicaid of at least $ 650000. The U.S. Attorney's Office in Charlotte said Wednesday that 37-year-old Charlotte Elizabeth Garnes is charged with health care fraud …
Read more on Sacramento Bee
County health care agency names new administrators
Cyndie Cole, part of the county system since 1985, has already begun work as hospital administrator and deputy director of the Ventura County Health Care Agency. She leads the 223-bed medical center in Ventura as well as the 49-bed Santa Paula Hospital …
Read more on Ventura County Star
Health 'reform' law deja-vu (again)
A similar feeling grips the reader of “An act improving the quality of health care and reducing costs through increased transparency, efficiency and innovation,” the Bay State's new health care bill signed into law this month. The “center for health …
Read more on Boston Herald
The pharmaceutical giant Glaxo SmithKline will pay billion in the largest healthcare fraud settlement in US history. The company covered up the drug risks and encouraged doctors to prescribe its products for uses they did not have approval for. From Washington, Al Jazeera’s Alan Fisher reports. Source, credit to Aljazeera- www.aljazeera.com FAIR USE NOTICE: This video has been posted to further advance our understanding of environmental, political, human rights, economic, Technological, democratic, scientific, and social justice issues which constitutes a “fair use” of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 USC Section 107 for research and educational purposes.
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From: www.youtube.com Please click Like on my FaceBook page here: www.facebook.com Subscribe to www.youtube.com July 02, 2012 – The pharmaceutical giant Glaxo SmithKline will pay billion in the largest healthcare fraud settlement in US history. The company covered up the drug risks and encouraged doctors to prescribe its products for uses they did not have approval for. From Washington, Al Jazeera’s Alan Fisherreports. FAIR USE NOTICE: This video may contain copyrighted material. Such material is made available for educational purposes only. This constitutes a ‘fair use’ of any such copyrighted material as provided for in Title 17 USC section 106A-117 of the US Copyright Law.
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A number of federal statutes aim to combat fraud and abuse in federally funded health care programs such as Medicare and Medicaid. Using these statutes, the federal government has been able to recover billions of dollars lost due to fraudulent activities. In March 2010, Congress enacted comprehensive health care reform legislation. One focus of this legislation, the Patient Protection and Affordable Care Act (PPACA) as amended, is improved health care fraud and abuse enforcement. PPACA, among other things, creates new health care fraud enforcement tools and expands upon the types of prohibited conduct. This report provides an overview of some of the more commonly used statutes used to fight health care fraud and abuse and discusses some of the changes made to these statutes by PPACA.
Title XI of the Social Security Act contains Medicare and Medicaid program-related anti-fraud provisions, which impose civil penalties, criminal penalties, as well as exclusions from federal health care programs on persons who engage in certain types of misconduct. PPACA amends these administrative sanctions and authorizes the imposition of several new civil monetary penalties and exclusions.
Under the federal anti-kickback statute, it is a felony for a person to knowingly and willfully offer, pay, solicit, or receive anything of value (i.e., “remuneration”) in return for a referral or to induce generation of business reimbursable under a federal health care program.The statute prohibits both the offer or payment of remuneration for patient referrals, as well as the offer or payment of anything of value in return for purchasing, leasing, ordering, or arranging for, or recommending the purchase, lease, or ordering of any item or service that is reimbursable by a federal health care program. PPACA revises the evidentiary standard under the anti-kickback statute and eliminates the requirement of actual knowledge of, or specific intent to commit a violation of the statute. This amendment may make it easier for the government to prove its case.
The Stark law and its implementing regulations prohibit physician self-referrals for certain health services that may be paid for by Medicare or Medicaid. Under the Stark law, if (1) a physician (or an immediate family member of a physician) has a “financial relationship” with an entity, the physician may not make a referral to the entity for the furnishing of these health services for which payment may be made under Medicare or Medicaid, and (2) the entity may not bill the federal health care program or any individual or entity for services furnished pursuant to a prohibited referral. PPACA limits certain exceptions to the Stark law.
The federal False Claims Act (FCA) imposes civil liability on persons who knowingly submit a false or fraudulent claim or engage in various types of misconduct involving federal government money or property. Health care program false claims often arise in billing, including billing for services not rendered, billing for unnecessary medical services, double billing for the same service or equipment, or billing for services at a higher rate than provided (“upcoding”). Civil actions may be brought in federal district court under the FCA by the Attorney General or by a person known as a relator (i.e., a “whistleblower”), for the person and for the U.S. Government, in what is termed a qui tam action. PPACA appears to make it easier for certain relators to bring qui tam actions, thus potentially allowing some FCA actions to proceed that would have been dismissed under prior law.
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(PRWEB) January 25, 2012
The Corporate Whistle Blower Center is urging professionals, executives, or managers in healthcare, in medical products, medical devices, or pharmaceuticals to step forward if they have substantial proof their company, or a company they know about is cheating, or defrauding the government out of millions of dollars in Medicare, or Medicaid fraud. The group says, “In the hospital business it could be a ER doctor, a CNO, or a CMO, who has proof their hospital is admitting ER patients, who should have been sent home, just to make a lot more money off of Medicare, or Medicaid. In the nursing home business it could be over medicating patients, to cover up the fact the nursing home is so short staffed, they do not have enough staff to provide the mandatory time per day to meet Medicare, or Medicaid requirements. In the medical device industry, an example could be surgeons in collusion with a medical device company’s representatives, that are selling extremely expensive titanium hip replacements to 90 year olds with dementia, when the patient could have received a hip replacement at a fraction of the cost, or when it comes to pharmaceutical companies the sky is the limit, when it comes to scams to over bill, or defraud the taxpayers.” http://CorporateWhistleBlowerCenter.Com
The Corporate Whistle Blower says, “We are in the business of helping whistleblowers advance their claims, with the goal being a huge reward, provided the wrongdoing is in the millions of dollars, and the whistleblower possesses significant proof, that makes it all easy to prove. Significant proof is not-I think they are doing this. Significant proof is being able to prove it with records, documents, or other witnesses.” The Corporate Whistle Blower Center treats all whistleblower calls with very strict rules. There is absolute confidentiality over things that are said. Based on the quality of the information, and the fact set quality, the Corporate Whistle Blower Center may try to help a whistleblower develop, or package their information, and based on the quality of the information the group will suggest what US law firms may be best suited to advance a claim. No other group in the world offers services like these. For more information whistleblowers, who possess significant, provable information are encouraged to contact the Corporate Whistle Blower Center anytime at 866-714-6466, or they can contact the group via their web site at http://CorporateWhistleBlowerCenter.Com
Simple rules for a whistleblower from the Corporate Whistle Blower Center:
Do not go to the government first, if you are a major whistleblower. The Corporate Whistle Blower Center says, “Major whistleblowers frequently go to the federal government thinking they will help. Its a huge mistake. Frequently government officials could care less, or they are incompetent.”
Do not go to the news media with your whistleblower information. Public revelation of a whistleblower’s information could destroy any prospect for a reward.
Do not try to force a government contractor, or corporation to come clean to the government about their wrongdoing. The Corporate Whistle Blower Center says, “Fraud is so rampant among federal contractors, that any suggestion of exposure might result in an instant job termination, or harassment of the whistleblower. We say, come to us first, tell us what type of information you have, and if we think its sufficient, we will help find the right law firms, to assist in advancing your information.”
Any type of insider, or employee, who possesses significant proof of their employer, or a government contractor fleecing the federal government is encouraged to contact to Corporate Whistle Blower Center anytime at 866-714-6466, or they can contact the group via their web site at http://CorporateWhistleBlowerCenter.com
Appleton, WI (PRWEB) January 18, 2012
Healthcare-billing fraud is a growing problem in the U.S. With his company, Argus Claim Review working on behalf of employers to cut healthcare costs, Tom Doney has become a leading advocate for cost containment and accountability in healthcare. Here, he explains how providers commit healthcare-billing fraud and how Argus saves employers thousands through its diligent watchdog efforts. Argus also shares five tips for employers to avoid excess medical claim charges at http://argusclaimreview.com/uploads/5_tips_for_employers_FINAL.pdf.
To most, trying to interpret a hospital bill or claim statement can be like reading a foreign language. After the dizzying experience of going through a few lines of diagnostic codes and descriptions, it can be tempting to give up and simply trust that all services have been billed accurately.
But the extra work is often times well worth the effort.
As healthcare-billing fraud continues to affect unsuspecting employers, the reality is that paying these bills without careful scrutiny can result in drastic overpayments by companies.
Tom Doney, CEO and co-founder of Argus Claim Review a national company with offices in Wisconsin, Nebraska, Oregon and Colorado has taken the lead in righting this wrong. Focused on cost containment in healthcare, Doney has been summoned to testify in front of the U.S. Department of Labor and serves as a leading spokesperson on the issue.
Though many billing inaccuracies turn out to be honest mistakes, Doney says healthcare-billing fraud and overcharging can take many forms.
It can be as simple as double billing a single service to as complex as intentionally misrepresenting the type of service provided, when it was provided or the identity of the patient, Doney explains. Other examples include billing for services or supplies that were never provided, altering a condition or diagnosis, inflating prices or unbundling services. He says upcoding, providing kickbacks or performing unnecessary tests/treatments with the sole intent to generate more revenue are more ways to sneak in extra charges.
While most providers would never think of purposely overcharging a patient, its the small percentage of others who are perpetuating the situation. And it results in rising healthcare costs with a significant ripple effect, since larger claims lead to larger premiums for employers and employees. It all contributes to spiraling costs, which some projections show are expected to climb to $ 3.6 trillion by 2014.
With todays dramatic economic struggles, thats something nobody wants to see happen.
To combat fraud and emphasize cost containment, Doney and his team have implemented Argus Claim Review, a solution for guarding against costly billing errors and claim deficiencies. Named after Greek Mythologys 100-eyed guardian who never sleeps, Doney explains, With our system, we are constantly on the lookout for claim errors and vigilant in our efforts to catch them, correct them and uncover savings on behalf of employers.
Things that can trigger a more intense claim review by Argus include network claims totaling over $ 10,000, dialysis and chemotherapy treatments, chronic pain management, multiple surgeries and anesthesiology.
Whether its a single dose of pain medication billed at 20 times the norm or the X-ray that was never performed, Doney is confident that his team will discover any inaccuracies.
The efforts are paying off. On average, Argus saves U.S. clients just over 46 percent on billed charges per claim reviewed, Doney reports. To show how this is done, Argus shares a healthcare-billing fraud prevention tip sheet on five of the top medical claim areas employers should monitor, including medical coding, charge accuracy, medical necessity, plan specifics and unbundling/upcoding.
For examples of everyday savings uncovered, Argus features several case studies on its website. Doney points out one example where Argus saved an employer over 75 percent on a large claim. In that instance, a Veterans Administration hospital charged $ 101,575.28 for a four-day stay; Argus researched the national pay rate for the Diagnosis Related Group (DRG) and ran claim data to see what Medicare would pay hospitals in a 50-mile radius, thus lowering the bill to under $ 23,000 and saving the employer a staggering $ 78,664.86.
What happens when healthcare fraud is, in fact, discovered? Oftentimes, claim specialists work with billing agencies to indicate errors and negotiate the appropriate charges on behalf of employers. Depending on the situation, providers can also be reported and investigated.
So rather than filing a claim away before closer review, companies should think of what the 100-eyed guardian and his team of sidekicks would do. The potential savings could mean thousands to a companys bottom line.
Headquartered in Appleton, Wis, Argus Claim Review features one of the industrys most comprehensive systems for guarding against error and fraudulent billing. For more information, visit http://www.argusclaimreview.com.
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Hanover Park, IL (PRWEB) February 15, 2012
ERISAclaim.com offers new healthcare executive webinars to discuss the FBI Press Release On Feb 14, 2012, that nearly $ 4.1 billion was recovered, as the largest sum ever recovered in single year, from Medicare overpayment and healthcare fraud. The Webinar will also assess what this $ 4.1 billion recovery means to all non-Medicare providers, as the private industry has been always following the Medicare footsteps in healthcare claims processing and overpayment recovery for criminal, civil fraud, and non-fraudulent but otherwise improperly obtained overpayment from non-Medicare health plans.
It is very important to know that nowadays the federal governmental agencies also unprecedentedly investigate and prosecute anyone for alleged healthcare fraud for non-Medicare health plans. So this Medicare anti-fraud news is for everyone who will never even deal with Medicare claims, said Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.
Many healthcare fraud investigations start with alleged overpayment, and more and more overpayment demand from payers in private sector imply or allege healthcare fraud while providers are completely clueless or careless, explained Dr. Zhou.
According the FBI National Press Releases on Feb. 14, 2012, Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $ 4.1 Billion, Largest Sum Ever Recovered in Single Year (http://www.fbi.gov/news/pressrel/press-releases/health-care-fraud-prevention-and-enforcement-efforts-result-in-record-breaking-recoveries-totaling-nearly-4.1-billion):
WASHINGTONAttorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today released a new report showing that the governments health care fraud prevention and enforcement efforts recovered nearly $ 4.1 billion in taxpayer dollars in fiscal year (FY) 2011. This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled.
Approximately $ 4.1 billion stolen or otherwise improperly obtained from federal health care programs was recovered and returned to the Medicare Trust Funds, the Treasury and others in FY 2011. This is an unprecedented achievement for HCFAC, a joint effort of the two departments to coordinate federal, state and local law enforcement activities to fight health care fraud and abuse.
While word stolen would mean for career criminals, otherwise improperly obtained could mean for unprecedented medical necessity fraud, billing & coding fraud, documentation fraud or marketing fraud, the kinds of the fraud that will be unprecedentedly faced by every healthcare provider, knowingly or unknowingly, commented Dr. Zhou.
The FBI Press Releases on Feb 14, 2012 also illustrated the epidemic seriousness of the unprecedented healthcare fraud investigation and convictions:
In FY 2011, the total number of cities with strike force prosecution teams was increased to nine, all of which have teams of investigators and prosecutors from the Justice Department, the FBI and the HHS Office of Inspector General, dedicated to fighting fraud. The strike force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes along with chronic fraud by criminals masquerading as health care providers or suppliers. In FY 2011, strike force operations charged a record number of 323 defendants, who allegedly collectively billed the Medicare program more than $ 1 billion. Strike force teams secured 172 guilty pleas, convicted 26 defendants at trial and sentenced 175 defendants to prison. The average prison sentence in strike force cases in FY 2011 was more than 47 months.
Last year, HHS OIG published a website, titled: HEAT Provider Compliance Training: Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training, for all healthcare providers and billing industry to be self educated proactively and voluntarily, in order to prevent any unintended violations, added Dr. Zhou. (http://oig.hhs.gov/compliance/provider-compliance-training/index.asp)
Unless in pure criminal and civil fraud cases, overpayment demand from payers in the private industry frequently imply or allege borderline fraud or questionable practice, according to Dr. Zhou.
The new ERISAclaim.com Executive Webinar will discuss the following topics:
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