FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN RESOURCES
President Announces New and Enhanced Initiatives to Support Older Americans
Feb 05, 2015
By: Nora Super, Executive Director, White House Conference on Aging
The President’s 2016 Budget will help ensure that older Americans enjoy not only longer but healthier lives. The Budget makes a number of commitments to enhance, advance, and create opportunity for older Americans, especially in the four focus areas of the 2015 White House Conference on Aging: retirement security, healthy aging, long-term care services and supports, and elder justice.
Let me say a little about a few of the Budget items in each area of focus:
To enhance retirement security, the President is committed to ensuring that Social Security is solvent and viable for the American people, now and in the future. The Administration will oppose any measures that privatize or weaken the Social Security system and will not accept an approach that slashes benefits for future generations or reduces basic benefits for current beneficiaries.
Additionally, as many as 78 million working Americans - about half the workforce - don't have a retirement savings plan at work. Fewer than 10 percent of those without plans at work contribute to a plan of their own. The President’s Budget expands retirement opportunities for all Americans to help families save and give them better choices to reach a secure retirement.
To support healthy aging, the Budget proposes a set of initiatives to strengthen Medicare by more closely aligning payments with the costs of providing care, encouraging health care providers to deliver better care and better outcomes for their patients, and improving access to care for beneficiaries. In addition, the Budget includes proposals that would build a stronger foundation for Medicare's future.
To provide relief from increased prescription drug costs, the Budget proposes to close the Medicare Part D donut hole for brand drugs by 2017, rather than 2020, by increasing discounts from the pharmaceutical industry. The Budget also proposes to provide the Secretary of Health and Human Services with new authority to negotiate with manufacturers on prices for high cost drugs and biologics covered under the Part D program. These proposals represent a few amongst a range of potential options, and the Administration looks forward to working with Congress to address growing drug costs.
Recognizing the importance of nutrition to healthy aging, the Budget provides over $874 million for Nutrition Services programs, a $60 million increase over the 2015 enacted level, allowing States to provide 208 million meals to over 2 million older Americans nation-wide, helping to halt the decline in service levels for the first time since 2010. In addition, the Budget helps provide supportive housing for very low-income elderly households, including frail elderly, to allow seniors to age in a stable environment and help them access human services.
To ensure older individuals and people with disabilities receive services in the most appropriate setting, the Budget proposes expanded access to Medicaid home and community-based long-term care services and supports. First, the Budget expands and simplifies eligibility to encourage more States to provide home and community-based care in their Medicaid programs. The Budget proposes expanding and improving the “Money Follows the Person”
Rebalancing demonstration, which helps States provide opportunities for older Americans and people with disabilities to transition back to the community from institutions. The Budget also includes a comprehensive long-term care pilot for up to five States to test, at an enhanced Federal match rate, a more streamlined approach to delivering long-term care services and supports to support greater access and improve quality of care.
The Budget also includes increased discretionary resources for the Aging and Disability Resource Centers (ADRCs) program, which make it easier for Americans nation-wide to learn about and access their health and long-term care services and support options. ADRCs support State efforts to create consumer-friendly entry points into long-term care services at the community level.
The Family Support Initiative will assist family members supporting older adults or people with disabilities across the lifespan. It will complement nearly $50 million in new resources for existing aging programs that are already providing critical help and supports to seniors and their caregivers, such as respite and transportation assistance.
To support evidence-based interventions to reduce elder abuse, neglect and financial exploitation, the Budget includes $25 million in discretionary resources for Elder Justice Act programs authorized under the Affordable Care Act. These resources will support standards and infrastructure to improve detection and reporting of elder abuse; grants to States to pilot a new reporting system; and funding to support a coordinated Federal research portfolio to better understand and prevent the abuse and exploitation of vulnerable adults.
Taken together, these and other initiatives in the Budget will help to change the aging landscape in America to reflect new realities and new opportunities for older Americans, and they will support the dignity, independence, and quality of life of older Americans at a time when we’re seeing a huge surge in the number of older adults.
As many of you are aware, 2015 marks the 50th Anniversary of Medicare, Medicaid, and the Older Americans Act, as well as the 80th Anniversary of Social Security. The commitments made to support older adults in the President’s Budget are a fitting way to mark these anniversaries, and to help fulfill the promise of a better future for older Americans—and for all of us—that is inherent in these landmark pieces of legislation.
Showing posts with label MEDICAID. Show all posts
Showing posts with label MEDICAID. Show all posts
Sunday, February 8, 2015
Tuesday, December 2, 2014
SLEEP THERAPY CO. SETTLES ALLEGATIONS OF VIOLATING FALSE CLAIMS ACT
FROM: THE JUSTICE DEPARTMENT
Monday, December 1, 2014
Government Settles False Claims Act Allegations Against Oxygen and Sleep Therapy Company
North Atlantic Medical Services Inc. (NAMS), doing business as Regional Home Care Inc., has agreed to pay $852,378 to resolve allegations that it violated the False Claims Act by submitting claims to Medicare and Medicaid for respiratory therapy services provided by unlicensed personnel, the Department of Justice announced today. NAMS is a medical device company based in Massachusetts that provides equipment and services for the treatment of respiratory ailments, such as oxygen deficiency and sleep apnea.
“Respiratory care services should be performed by properly licensed personnel,” said Acting Assistant Attorney General Joyce R. Branda for the Civil Division. “We will not tolerate companies prioritizing their own profits and convenience at the expense of patient safeguards.”
Medicare and Medicaid require suppliers of respiratory therapy equipment and services to comply with state licensing standards. In Massachusetts, the Department of Public Health requires respiratory therapists to apply for and obtain a license. Applicants can do so by passing the National Board for Respiratory Care’s “Certification Examination for Entry-Level Respiratory Therapy Practitioners” or obtaining a reciprocal license from a different jurisdiction. This settlement resolves allegations that, from September 2010 to January 2013, NAMS used unlicensed employees to set up sleep apnea masks and oxygen therapy equipment for patients in Massachusetts. The government alleged that, even after the Massachusetts Department of Public Health informed the company that the practice was illegal, NAMS continued to use unlicensed personnel and bill Medicare and Medicaid for these services.
“This respiratory care company flouted important licensure requirements, failed to provide patients the standard of care that they deserve and fraudulently billed the federal government for improperly rendered services,” said U.S. Attorney Carmen M. Ortiz for the District of Massachusetts. “With the important assistance of whistleblowers, our health care fraud team seeks to ensure patient safety and protect the public fisc.”
“To safeguard patient health and ensure that taxpayer money is spent well, Medicare and Medicaid require providers of respiratory care services to follow state licensure rules,” said Special Agent in Charge Phillip M. Coyne for the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Companies seeking to boost profits by using unlicensed personnel will be held accountable for their actions.”
Medicaid is jointly funded by the states and federal government. The Commonwealth of Massachusetts, which paid in part for the Medicaid claims at issue, will receive $229,210 of the settlement amount.
The government’s investigation was initiated by a qui tam, or whistleblower, lawsuit filed under the False Claims Act by former NAMS employees Konstantinos Gakis and Demetri Papageorgiou. The False Claims Act allows private citizens to file suit for false claims on behalf of the government and to share in the government’s recovery. Gakis and Papageorgiou will receive $153,428.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $23.2 billion through False Claims Act cases, with more than $14.9 billion of that amount recovered in cases involving fraud against federal health care programs.
This settlement was the result of a coordinated effort by the Civil Division, the U.S. Attorney’s Office for the District of Massachusetts, FBI, HHS-OIG, and the Commonwealth of Massachusetts.
Monday, December 1, 2014
Government Settles False Claims Act Allegations Against Oxygen and Sleep Therapy Company
North Atlantic Medical Services Inc. (NAMS), doing business as Regional Home Care Inc., has agreed to pay $852,378 to resolve allegations that it violated the False Claims Act by submitting claims to Medicare and Medicaid for respiratory therapy services provided by unlicensed personnel, the Department of Justice announced today. NAMS is a medical device company based in Massachusetts that provides equipment and services for the treatment of respiratory ailments, such as oxygen deficiency and sleep apnea.
“Respiratory care services should be performed by properly licensed personnel,” said Acting Assistant Attorney General Joyce R. Branda for the Civil Division. “We will not tolerate companies prioritizing their own profits and convenience at the expense of patient safeguards.”
Medicare and Medicaid require suppliers of respiratory therapy equipment and services to comply with state licensing standards. In Massachusetts, the Department of Public Health requires respiratory therapists to apply for and obtain a license. Applicants can do so by passing the National Board for Respiratory Care’s “Certification Examination for Entry-Level Respiratory Therapy Practitioners” or obtaining a reciprocal license from a different jurisdiction. This settlement resolves allegations that, from September 2010 to January 2013, NAMS used unlicensed employees to set up sleep apnea masks and oxygen therapy equipment for patients in Massachusetts. The government alleged that, even after the Massachusetts Department of Public Health informed the company that the practice was illegal, NAMS continued to use unlicensed personnel and bill Medicare and Medicaid for these services.
“This respiratory care company flouted important licensure requirements, failed to provide patients the standard of care that they deserve and fraudulently billed the federal government for improperly rendered services,” said U.S. Attorney Carmen M. Ortiz for the District of Massachusetts. “With the important assistance of whistleblowers, our health care fraud team seeks to ensure patient safety and protect the public fisc.”
“To safeguard patient health and ensure that taxpayer money is spent well, Medicare and Medicaid require providers of respiratory care services to follow state licensure rules,” said Special Agent in Charge Phillip M. Coyne for the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Companies seeking to boost profits by using unlicensed personnel will be held accountable for their actions.”
Medicaid is jointly funded by the states and federal government. The Commonwealth of Massachusetts, which paid in part for the Medicaid claims at issue, will receive $229,210 of the settlement amount.
The government’s investigation was initiated by a qui tam, or whistleblower, lawsuit filed under the False Claims Act by former NAMS employees Konstantinos Gakis and Demetri Papageorgiou. The False Claims Act allows private citizens to file suit for false claims on behalf of the government and to share in the government’s recovery. Gakis and Papageorgiou will receive $153,428.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $23.2 billion through False Claims Act cases, with more than $14.9 billion of that amount recovered in cases involving fraud against federal health care programs.
This settlement was the result of a coordinated effort by the Civil Division, the U.S. Attorney’s Office for the District of Massachusetts, FBI, HHS-OIG, and the Commonwealth of Massachusetts.
Wednesday, November 26, 2014
U.S. FILES LAWSUIT CLAIMING COMPANY BILLED GOVERNMENT FOR INELIGIBLE PATIENTS
FROM: U.S. JUSTICE DEPARTMENT
Tuesday, November 25, 2014
United States Files False Claims Act Lawsuit Against Las Vegas Hospice and Related Entities for Billing Medicare and Medicaid for Ineligible Patients
The United States has filed suit against Creekside Hospice II LLC, Skilled Healthcare Group Inc. (SKG), its holding company, and Skilled Healthcare LLC (SKH), an administrative services subsidiary of SKG that operates Creekside (collectively the Creekside entities), alleging that these entities knowingly submitted ineligible claims for hospice services and inflated claims for patient visits to government health care programs, the Justice Department announced today.
“The Medicare hospice benefit is intended to provide pain management and other palliative care to patients nearing the end of life, to help make them as comfortable as possible,” said Acting Assistant Attorney General Joyce R. Branda for the Civil Division. “Too often, however, companies abuse this critical service by using aggressive marketing tactics to pressure patients who do not need, and may be ill-served, by these services in order to get higher reimbursements from the government. The department will take swift action to protect taxpayer dollars and make sure that Medicare benefits are available to those who truly need them.”
The Medicare and Medicaid hospice benefits are available for patients who elect palliative treatment (medical care focused on providing patients with relief from pain and stress) for a terminal illness and have a life expectancy of six months or less if their disease runs its normal course. When Medicare or Medicaid patients receive hospice services, they no longer receive services designed to cure their illnesses.
The government’s complaint alleges that the Creekside entities knowingly submitted or caused the submission of false claims for hospice care for patients who were not terminally ill. According to the complaint, the companies allegedly directed staff to enroll patients in the hospice program regardless of the patients’ eligibility for hospice benefits, sometimes by instructing staff to change records after the hospice submitted claims for payment to indicate that all requirements had been met. Management from Creekside, SKG and SKH also allegedly instructed employees to alter medical records to make it appear that doctors at the hospice had conducted personal visits with the patients, when in fact they had not occurred, in order to ensure reimbursement from Medicare and Medicaid. The complaint alleges that Creekside management aggressively discouraged staff from permitting patients or their families to revoke their elections to accept hospice benefits. The complaint also alleges that staff at Creekside were discouraged from documenting known improvements in a patient’s health in the medical record, called “Chart Killers” by the hospice, to ensure that Medicare or Medicaid would pay the hospice’s claim.
Further, the complaint alleges that the Creekside entities knowingly submitted or caused the submission of inflated claims to Medicare for services performed by the medical director. The government alleges that the companies repeatedly used billing codes that resulted in higher payment by Medicare than were justified by the services actually performed. As a result of the conduct alleged in the complaint, the government contends that the Creekside entities misspent tens of millions of taxpayer dollars from the Medicare and Medicaid programs.
“In order to protect the financial integrity of the Medicare and Medicaid programs, upon which so many of our senior American citizens rely, both the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) have made combating healthcare fraud an enforcement priority,” said U.S. Attorney Daniel G. Bogden for the District of Nevada. “This type of fraud will not be tolerated and DOJ and HHS will act swiftly when it does occur to pursue False Claims Act suits against violators.”
The United States filed its complaint in two consolidated lawsuits brought under the whistleblower provisions of the False Claims Act and the Nevada False Claims Act by Joanne Cretney-Tsosie, a clinical manager for Creekside, and Veneta Lepera, a former clinical manager for Creekside. Under these statutes, a private citizen can sue for fraud on behalf of the United States and the state of Nevada, respectively, and share in any recovery. The federal and state governments are entitled to intervene in such a lawsuit, as they have done in this case.
The United States’ suit is part of the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $23.1 billion through False Claims Act cases, with more than $14.8 billion of that amount recovered in cases involving fraud against federal health care programs.
This matter was investigated by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office for the District of Nevada, the Nevada Attorney General’s Office and the HHS Office of Inspector General. The claims asserted against Creekside Hospice, SKG and SKH are allegations only and there has been no determination of liability.
Tuesday, November 25, 2014
United States Files False Claims Act Lawsuit Against Las Vegas Hospice and Related Entities for Billing Medicare and Medicaid for Ineligible Patients
The United States has filed suit against Creekside Hospice II LLC, Skilled Healthcare Group Inc. (SKG), its holding company, and Skilled Healthcare LLC (SKH), an administrative services subsidiary of SKG that operates Creekside (collectively the Creekside entities), alleging that these entities knowingly submitted ineligible claims for hospice services and inflated claims for patient visits to government health care programs, the Justice Department announced today.
“The Medicare hospice benefit is intended to provide pain management and other palliative care to patients nearing the end of life, to help make them as comfortable as possible,” said Acting Assistant Attorney General Joyce R. Branda for the Civil Division. “Too often, however, companies abuse this critical service by using aggressive marketing tactics to pressure patients who do not need, and may be ill-served, by these services in order to get higher reimbursements from the government. The department will take swift action to protect taxpayer dollars and make sure that Medicare benefits are available to those who truly need them.”
The Medicare and Medicaid hospice benefits are available for patients who elect palliative treatment (medical care focused on providing patients with relief from pain and stress) for a terminal illness and have a life expectancy of six months or less if their disease runs its normal course. When Medicare or Medicaid patients receive hospice services, they no longer receive services designed to cure their illnesses.
The government’s complaint alleges that the Creekside entities knowingly submitted or caused the submission of false claims for hospice care for patients who were not terminally ill. According to the complaint, the companies allegedly directed staff to enroll patients in the hospice program regardless of the patients’ eligibility for hospice benefits, sometimes by instructing staff to change records after the hospice submitted claims for payment to indicate that all requirements had been met. Management from Creekside, SKG and SKH also allegedly instructed employees to alter medical records to make it appear that doctors at the hospice had conducted personal visits with the patients, when in fact they had not occurred, in order to ensure reimbursement from Medicare and Medicaid. The complaint alleges that Creekside management aggressively discouraged staff from permitting patients or their families to revoke their elections to accept hospice benefits. The complaint also alleges that staff at Creekside were discouraged from documenting known improvements in a patient’s health in the medical record, called “Chart Killers” by the hospice, to ensure that Medicare or Medicaid would pay the hospice’s claim.
Further, the complaint alleges that the Creekside entities knowingly submitted or caused the submission of inflated claims to Medicare for services performed by the medical director. The government alleges that the companies repeatedly used billing codes that resulted in higher payment by Medicare than were justified by the services actually performed. As a result of the conduct alleged in the complaint, the government contends that the Creekside entities misspent tens of millions of taxpayer dollars from the Medicare and Medicaid programs.
“In order to protect the financial integrity of the Medicare and Medicaid programs, upon which so many of our senior American citizens rely, both the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) have made combating healthcare fraud an enforcement priority,” said U.S. Attorney Daniel G. Bogden for the District of Nevada. “This type of fraud will not be tolerated and DOJ and HHS will act swiftly when it does occur to pursue False Claims Act suits against violators.”
The United States filed its complaint in two consolidated lawsuits brought under the whistleblower provisions of the False Claims Act and the Nevada False Claims Act by Joanne Cretney-Tsosie, a clinical manager for Creekside, and Veneta Lepera, a former clinical manager for Creekside. Under these statutes, a private citizen can sue for fraud on behalf of the United States and the state of Nevada, respectively, and share in any recovery. The federal and state governments are entitled to intervene in such a lawsuit, as they have done in this case.
The United States’ suit is part of the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $23.1 billion through False Claims Act cases, with more than $14.8 billion of that amount recovered in cases involving fraud against federal health care programs.
This matter was investigated by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office for the District of Nevada, the Nevada Attorney General’s Office and the HHS Office of Inspector General. The claims asserted against Creekside Hospice, SKG and SKH are allegations only and there has been no determination of liability.
Friday, November 14, 2014
COMPANY AND AFFILIATES AGREE TO PAY OVER $25 MILLION TO SETTLE FALSE CLAIMS ALLEGATIONS
FROM: U.S. JUSTICE DEPARTMENT
Wednesday, November 12, 2014
Careall Companies Agree to Pay $25 Million to Settle False Claims Act Allegations
CareAll Management LLC and its affiliated entities (collectively “CareAll”) have agreed to pay $25 million, plus interest, to the United States and the state of Tennessee to resolve allegations that CareAll violated the False Claims Act by submitting false and upcoded home healthcare billings to the Medicare and Medicaid programs, the Department of Justice announced today. CareAll is based in Nashville, Tennessee, and is one of Tennessee’s largest home health providers.
“Home health agencies may only bill Medicare and Medicaid for care that is necessary and covered by the programs,” said Acting Assistant Attorney General Joyce R. Branda for the Justice Department’s Civil Division. “This settlement is another example of the department’s commitment to ensuring that home health care dollars – which are so vital to ensure the care of homebound patients – are spent for their intended purposes.”
This settlement resolves allegations that between 2006 and 2013, CareAll overstated the severity of patients’ conditions to increase billings and billed for services that were not medically necessary and rendered to patients who were not homebound.
“This case demonstrates that enforcement of the False Claims Act is a priority of the U.S. Attorney’s Office for the Middle District of Tennessee,” said U.S. Attorney David Rivera for the Middle District of Tennessee. “The U.S. Attorney’s Office and our law enforcement partners are committed to protecting the public and vigorously pursuing all those who knowingly submit false claims affecting the Medicare and Medicaid programs.”
This is CareAll’s second settlement of alleged False Claims Act violations within the last two years. In 2012, CareAll paid nearly $9.38 million for allegedly submitting false cost reports to Medicare. As part of the settlement announced today, the companies agreed to be bound by the terms of an enhanced and extended corporate integrity agreement with the Department of Health and Human Services-Office of Inspector General (HHS-OIG) in an effort to avoid future fraud and compliance failures.
“Fraudulent home-based services are surging across the country,” said Special Agent in Charge Derrick L. Jackson of HHS-OIG in Atlanta. “We will continue to protect both Medicare and taxpayers, and ensure that funds are not siphoned off by companies more concerned with the bottom line than patient care.”
Under the False Claims Act, private citizens, known as relators, can bring suit on behalf of the United States and share in any recovery. The relator in this case, Toney Gonzales, will receive more than $3.9 million as his share of the recovery.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of HHS. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $23.1 billion through False Claims Act cases, with more than $14.8 billion of that amount recovered in cases involving fraud against federal health care programs.
The settlement was the result of a coordinated effort by the Civil Division, the U.S. Attorney’s Office for the Middle District of Tennessee, HHS-OIG and the Tennessee Bureau of Investigation.
The case is docketed as United States ex rel. Gonzales v. J.W. Carell Enterprises, Inc., et al., No. 12-0389 (M.D. Tenn.). The claims resolved by the settlement are allegations only; there has been no determination of liability.
Wednesday, November 12, 2014
Careall Companies Agree to Pay $25 Million to Settle False Claims Act Allegations
CareAll Management LLC and its affiliated entities (collectively “CareAll”) have agreed to pay $25 million, plus interest, to the United States and the state of Tennessee to resolve allegations that CareAll violated the False Claims Act by submitting false and upcoded home healthcare billings to the Medicare and Medicaid programs, the Department of Justice announced today. CareAll is based in Nashville, Tennessee, and is one of Tennessee’s largest home health providers.
“Home health agencies may only bill Medicare and Medicaid for care that is necessary and covered by the programs,” said Acting Assistant Attorney General Joyce R. Branda for the Justice Department’s Civil Division. “This settlement is another example of the department’s commitment to ensuring that home health care dollars – which are so vital to ensure the care of homebound patients – are spent for their intended purposes.”
This settlement resolves allegations that between 2006 and 2013, CareAll overstated the severity of patients’ conditions to increase billings and billed for services that were not medically necessary and rendered to patients who were not homebound.
“This case demonstrates that enforcement of the False Claims Act is a priority of the U.S. Attorney’s Office for the Middle District of Tennessee,” said U.S. Attorney David Rivera for the Middle District of Tennessee. “The U.S. Attorney’s Office and our law enforcement partners are committed to protecting the public and vigorously pursuing all those who knowingly submit false claims affecting the Medicare and Medicaid programs.”
This is CareAll’s second settlement of alleged False Claims Act violations within the last two years. In 2012, CareAll paid nearly $9.38 million for allegedly submitting false cost reports to Medicare. As part of the settlement announced today, the companies agreed to be bound by the terms of an enhanced and extended corporate integrity agreement with the Department of Health and Human Services-Office of Inspector General (HHS-OIG) in an effort to avoid future fraud and compliance failures.
“Fraudulent home-based services are surging across the country,” said Special Agent in Charge Derrick L. Jackson of HHS-OIG in Atlanta. “We will continue to protect both Medicare and taxpayers, and ensure that funds are not siphoned off by companies more concerned with the bottom line than patient care.”
Under the False Claims Act, private citizens, known as relators, can bring suit on behalf of the United States and share in any recovery. The relator in this case, Toney Gonzales, will receive more than $3.9 million as his share of the recovery.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of HHS. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $23.1 billion through False Claims Act cases, with more than $14.8 billion of that amount recovered in cases involving fraud against federal health care programs.
The settlement was the result of a coordinated effort by the Civil Division, the U.S. Attorney’s Office for the Middle District of Tennessee, HHS-OIG and the Tennessee Bureau of Investigation.
The case is docketed as United States ex rel. Gonzales v. J.W. Carell Enterprises, Inc., et al., No. 12-0389 (M.D. Tenn.). The claims resolved by the settlement are allegations only; there has been no determination of liability.
Saturday, October 11, 2014
ACTING AG DELERY MAKES REMARKS REGARDING EXTENDICARE FALSE CLAIMS ACT CASE
FROM: U.S. JUSTICE DEPARTMENT
Acting Associate Attorney General Stuart F. Delery Delivers Remarks at Press Conference Announcing False Claims Act Resolution with Extendicare
Washington, DCUnited States ~ Friday, October 10, 2014
Remarks as Prepared for Delivery
Good morning and thank you all for being here today. I am pleased to be joined by Joyce Branda, the Acting Assistant Attorney General for the Civil Division, as well as Gregory Demske, the Chief Counsel to the Inspector General for the Department of Health and Human Services.
Protecting this nation’s vulnerable populations – including our seniors – has been, and continues to be, one of this department’s highest priorities. As more and more seniors rely on nursing homes for care, it becomes increasingly important for us to ensure that they receive the services they need.
Today, we are here to announce that Extendicare Health Services – one of the nation’s largest nursing home chains with 146 facilities in 11 states – has agreed to pay $38 million to resolve allegations that certain of its facilities billed the Medicare and Medicaid programs for nursing care services that were so grossly substandard as to be effectively worthless, while also billing Medicare for medically unreasonable and unnecessary rehabilitation therapy services. This is the largest False Claims Act settlement the department has entered with a nursing home chain involving “failure of care” allegations.
As part of this historic resolution, Extendicare will also enter into a five year chain-wide corporate integrity agreement with the Department of Health and Human Services. This agreement will contain innovative staffing requirements intended to ensure that this type of misconduct will not happen again.
This significant resolution reflects a convergence of two of the department’s highest priorities.
First, today’s settlement reflects the department’s commitment to protecting the nation’s elderly and most vulnerable citizens from all forms of abuse, neglect, and financial exploitation. Under this administration, the department has redoubled its efforts in the elder justice arena by funding innovative research, developing training materials for elder abuse prosecutors and legal services lawyers; and by raising public awareness. In fact, just last month, the department launched its Elder Justice Website, a tremendous resource for prosecutors, practitioners, and most importantly, elder abuse victims and their families.
Second, today’s settlement reflects the department’s commitment to combatting health care fraud. Given the growing Medicare eligible population, we must make every effort to protect Medicare funds from fraud, waste, and abuse. Since the Attorney General and the Secretary for Health and Human Services launched the Health Care Fraud Prevention and Enforcement Action Team initiative in 2009, the department has recovered over $14 billion in cases involving fraud against federal healthcare programs. The department has aggressively pursued healthcare fraud against virtually every type of healthcare provider and supplier, including hospitals, physicians, hospice providers, and pharmaceutical and device manufacturers. Today’s settlement with Extendicare is an example of this initiative in action.
Taken as a whole, today’s resolution represents an important achievement on both those fronts. Our seniors rely on the Medicare and Medicaid programs to provide them with quality care, dignity and respect when they are most vulnerable. It is, therefore, critically important that we hold accountable those healthcare providers, including nursing home operators, who put their own economic gain over the needs of their residents.
We will pursue with equal vigor those who bill Medicare and Medicaid while failing to provide beneficiaries with the nursing care to which they are entitled and those who provide medically unnecessary services in order to maximize their Medicare billings. Both of these schemes are forms of elder financial exploitation. Neither will be tolerated by this department.
Finally, before I turn things over to Acting Assistant Attorney General Joyce Branda, I wanted to commend the excellent work of the Extendicare team. Given the scope of the allegations at issue, the investigation was conducted jointly by the Department of Justice’s Civil Division, several U.S. Attorney’s Offices, agents and attorneys from the HHS Office of Inspector General, as well as attorneys and agents from the Medicaid Fraud Control Units of several states. This settlement, and the underlying investigation, is a compelling example of how federal and state law enforcement can work effectively together and of what we can achieve when we do so. I am pleased that we are joined here today by representatives of those offices.
With that, I’m happy to introduce Joyce Branda, the Acting Assistant Attorney General for the Civil Division, who will discuss the Extendicare settlement in more detail.
Tuesday, July 15, 2014
HHS SECRETARY ANNOUNCES NEW COLLABORATION WITH STATES TO IMPROVE MEDICAID BENEFICIARY CARE
FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
New resources improve states’ abilities to advance Medicaid payment and delivery system reform
This initiative is consistent with states’ recommendation that the Centers for Medicare & Medicaid Services (CMS) identify opportunities for care improvement and addressing high priority areas such as mental health and emergency department utilization. Through the Medicaid Innovation Accelerator Program, HHS is investing over $100 million in technical support to help states in their efforts to improve health, improve care and decrease costs for their Medicaid beneficiaries. While complementing other federal-state delivery system reform efforts such as the State Innovation Models initiative, this new initiative will help jumpstart innovation by providing federal tools and resources to support states in advancing Medicaid-specific delivery system reform.
“Medicaid innovation is moving forward, and the new Medicaid Innovation Accelerator Program, announced in response to recommendations from Governors, will give states the opportunity to even further strengthen their great work,” said Secretary Burwell. “HHS will provide strategically targeted resources that states can leverage to enhance the impact of their efforts to transform health care.”
“We are very pleased by this new effort to develop performance partnerships with states that can deliver better health outcomes at a cost we can afford,” said Oregon Gov. John Kitzhaber. “Using the reform principles developed by a bipartisan NGA Health Care Sustainability Task Force that I co-chaired with Governor Haslam, Oregon has begun to prove these principles can deliver. We look forward to working with HHS, NGA and other states to scale this work.”
“The Task Force's recommendations highlighted many key areas that needed reform, and I appreciate the continued conversations CMS has had with us about these areas," said Tennessee Gov. Bill Haslam. "This new initiative and investment demonstrate that there is great benefit to state-federal collaboration.”
The Medicaid Innovation Accelerator Program will develop Medicaid specific resources to support state-based innovative health care reform efforts by identifying and advancing new Medicaid service delivery and financing models to improve patient care by providing data analytics, improving quality measurement and rapid cycle evaluation capabilities, and advancing effective and timely dissemination of best practices and learning among states.
Monday, June 30, 2014
LARGEST U.S. NURSING HOME PHARMACY COMPANY SETTLES FALSE BILLINGS ALLEGATIONS FOR $124 MILLION
FROM: U.S. JUSTICE DEPARTMENT
Wednesday, June 25, 2014
Nation’s Largest Nursing Home Pharmacy Company to Pay $124 Million to Settle Allegations Involving False Billings to Federal Health Care Programs
Omnicare Inc., the nation’s largest provider of pharmaceuticals and pharmacy services to nursing homes, has agreed to pay $124.24 million for allegedly offering improper financial incentives to skilled nursing facilities in return for their continued selection of Omnicare to supply drugs to elderly Medicare and Medicaid beneficiaries, the Justice Department announced today . Omnicare is headquartered in Cincinnati, Ohio.
“Health care providers who seek to profit from providing illegal financial benefits will be held accountable,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “Schemes such as this one undermine the health care system and take advantage of elderly nursing home residents.”
“Omnicare provided improper discounts in return for the opportunity to provide medication to Medicare and Medicaid beneficiaries,” said Steven M. Dettelbach, United States Attorney for the Northern District of Ohio. “Nursing homes should select their pharmacy provider based on the best quality, service and cost to the residents, not based on improper discounts to the nursing facility.”
The settlement resolves allegations that Omnicare submitted false claims by entering into below-cost contracts to supply prescription medication and other pharmaceutical drugs to skilled nursing facilities and their resident patients to induce the facilities to select Omnicare as their pharmacy provider. The facilities were participating providers under agreements with Medicare and Medicaid. In addition to the facilities’ own claims for reimbursement from Medicare for short-term rehabilitation treatment rendered to patients, Omnicare submitted additional claims for reimbursement to Medicare and Medicaid for drugs Omnicare supplied. Of the $124.24 million to be paid by Omnicare, $8.24 million will go to various states which jointly funded the Medicaid programs impacted by Omnicare’s conduct.
The Anti-Kickback Statute prohibits offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid and other federally funded programs. The Anti-Kickback Statute is intended to ensure that the selection of health care providers and suppliers is not compromised by improper financial incentives and is instead based on the best interests of the patient.
The settlement resolves allegations brought in two lawsuits filed by whistleblowers under the qui tam provisions of the False Claims Act, which allow private parties to bring suit on behalf of the government and to share in any recovery. The first whistleblower, Donald Gale, a former Omnicare employee, will receive $ 17.24 million.
The settlement with Omnicare was the result of a coordinated effort by the U.S. Attorney’s Office for the Northern District of Ohio, the Commercial Litigation Branch of the Justice Department’s Civil Division, the Department of Health and Human Services Office of Inspector General, and the National Association of Medicaid Fraud Control Units.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $19.5 billion through False Claims Act cases, with more than $13.9 billion of that amount recovered in cases involving fraud against federal health care programs.
The claims resolved by this settlement are allegations only, and there has been no determination of liability.
Tuesday, June 3, 2014
HHS HAS NEW DATA, TOOLS TO INCREASE HOSPITAL UTILIZATION TRANSPARENCY
FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
HHS releases new data and tools to increase transparency on hospital utilization and other trends
Data can help improve care coordination and health outcomes for Medicare beneficiaries
With more than 2,000 entrepreneurs, investors, data scientists, researchers, policy experts, government employees and more in attendance, the Department of Health and Human Services (HHS) is releasing new data and launching new initiatives at the annual Health Datapalooza conference in Washington, D.C.
Today, the Centers for Medicare & Medicaid Services (CMS) is releasing its first annual update to the Medicare hospital charge data, or information comparing the average amount a hospital bills for services that may be provided in connection with a similar inpatient stay or outpatient visit. CMS is also releasing a suite of other data products and tools aimed to increase transparency about Medicare payments. The data trove on CMS’s website now includes inpatient and outpatient hospital charge data for 2012, and new interactive dashboards for the CMS Chronic Conditions Data Warehouse and geographic variation data. Also today, the Food and Drug Administration (FDA) will launch a new open data initiative. And before the end of the conference, the Office of the National Coordinator for Health Information Technology (ONC) will announce the winners of two data challenges.
“The release of these data sets furthers the administration’s efforts to increase transparency and support data-driven decision making which is essential for health care transformation,” said HHS Secretary Kathleen Sebelius.
“These public data resources provide a better understanding of Medicare utilization, the burden of chronic conditions among beneficiaries and the implications for our health care system and how this varies by where beneficiaries are located,” said Bryan Sivak, HHS chief technology officer. “This information can be used to improve care coordination and health outcomes for Medicare beneficiaries nationwide, and we are looking forward to seeing what the community will do with these releases. Additionally, the openFDA initiative being launched today will for the first time enable a new generation of consumer facing and research applications to embed relevant and timely data in machine-readable, API-based formats."
2012 Inpatient and Outpatient Hospital Charge Data
The data posted today on the CMS website provide the first annual update of the hospital inpatient and outpatient data released by the agency last spring. The data include information comparing the average charges for services that may be provided in connection with the 100 most common Medicare inpatient stays at over 3,000 hospitals in all 50 states and Washington, D.C. Hospitals determine what they will charge for items and services provided to patients and these “charges” are the amount the hospital generally bills for those items or services.
With two years of data now available, researchers can begin to look at trends in hospital charges. For example, average charges for medical back problems increased nine percent from $23,000 to $25,000, but the total number of discharges decreased by nearly 7,000 from 2011 to 2012.
In April, ONC launched a challenge – the Code-a-Palooza challenge – calling on developers to create tools that will help patients use the Medicare data to make health care choices. Fifty-six innovators submitted proposals and 10 finalists are presenting their applications during Datapalooza. The winning products will be announced before the end of the conference.
Chronic Conditions Warehouse and Dashboard
CMS recently released new and updated information on chronic conditions among Medicare fee-for-service beneficiaries, including:
Geographic data summarized to national, state, county, and hospital referral regions levels for the years 2008-2012;
Data for examining disparities among specific Medicare populations, such as beneficiaries with disabilities, dual-eligible beneficiaries, and race/ethnic groups;
Data on prevalence, utilization of select Medicare services, and Medicare spending;
Interactive dashboards that provide customizable information about Medicare beneficiaries with chronic conditions at state, county, and hospital referral regions levels for 2012; and Chartbooks and maps.
These public data resources support the HHS Initiative on Multiple Chronic Conditions by providing researchers and policymakers a better understanding of the burden of chronic conditions among beneficiaries and the implications for our health care system.
Geographic Variation Dashboard
The Geographic Variation Dashboards present Medicare fee-for-service per-capita spending at the state and county levels in interactive formats. CMS calculated the spending figures in these dashboards using standardized dollars that remove the effects of the geographic adjustments that Medicare makes for many of its payment rates. The dashboards include total standardized per capita spending, as well as standardized per capita spending by type of service. Users can select the indicator and year they want to display. Users can also compare data for a given state or county to the national average. All of the information presented in the dashboards is also available for download from the Geographic Variation Public Use File.
Research Cohort Estimate Tool
CMS also released a new tool that will help researchers and other stakeholders estimate the number of Medicare beneficiaries with certain demographic profiles or health conditions. This tool can assist a variety of stakeholders interested in specific figures on Medicare enrollment. Researchers can also use this tool to estimate the size of their proposed research cohort and the cost of requesting CMS data to support their study.
Digital Privacy Notice Challenge
ONC, with the HHS Office of Civil Rights, will be awarding the winner of the Digital Privacy Notice Challenge during the conference. The winning products will help consumers get notices of privacy practices from their health care providers or health plans directly in their personal health records or from their providers’ patient portals.
OpenFDA
The FDA’s new initiative, openFDA, is designed to facilitate easier access to large, important public health datasets collected by the agency. OpenFDA will make FDA’s publicly available data accessible in a structured, computer readable format that will make it possible for technology specialists, such as mobile application creators, web developers, data visualization artists and researchers to quickly search, query, or pull massive amounts of information on an as needed basis. The initiative is the result of extensive research to identify FDA’s publicly available datasets that are often in demand, but traditionally difficult to use. Based on this research, openFDA is beginning with a pilot program involving millions of reports of drug adverse events and medication errors submitted to the FDA from 2004 to 2013. The pilot will later be expanded to include the FDA’s databases on product recalls and product labeling.
Tuesday, May 27, 2014
HHS SECRETARY ANNOUNCES DELIVERY SYSTEM REFORM FOR HEALTH CARE
FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
New funding gives states and innovators tools and flexibility to implement delivery system reform
Health and Human Services Secretary Kathleen Sebelius today announced new delivery system reform efforts made possible by the Affordable Care Act that offer states and innovators tools and flexibility to transform health care.
HHS announced twelve prospective recipients receiving as much as $110 million in combined funding, ranging from an expected $2 million to $18 million over a three-year period, under the Health Innovation Awards program to test innovative models designed to deliver better care outcomes and lower costs. Examples include projects to provide better care for dementia patients, improve coordination between specialists and primary care physicians, and to improve cardiac care. Round two of the Health Care Innovation Awards program focuses on four priority areas: rapidly reducing costs for patients with Medicare and Medicaid; improving care for populations with specialized needs; testing improved financial and clinical models for specific types of providers, including specialists; and linking clinical care delivery to preventive and population health. The twelve prospective recipients will test models in all four categories and spanning 13 states. Additional prospective recipients will be announced in the coming months.
Also today, HHS made up to $730 million available as part of the State Innovation Model initiative to help states design and test improvements to their public and private health care payment and delivery systems. Project goals are to improve health, improve care, and decrease costs for consumers, including Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.
“As a former governor, I understand the real sense of urgency states and local communities feel to improve the health of their populations while also reducing health care costs, and it’s critical that the many elements of health care in each state – including Medicaid, public health, and workforce training – work together,” Secretary Sebelius said. “To help, HHS will continue to encourage and assist them in their efforts to transform health care.
“These efforts will strengthen federal, state, and local partnerships, encourage broad stakeholder engagement, and capitalize on federal resources to ensure greater transformation of delivery of health care services,” said Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner.
The twelve innovative projects announced today represent the first batch of prospective recipients for round two of Health Care Innovation Awards program funding. In 2012, 107 organizations located in urban and rural areas, all 50 states, the District of Columbia and Puerto Rico received awards through round one of the initiative.
As part of the State Innovation Model initiative, states, territories and the District of Columbia can apply for either a Model Test award to assist in implementation or a Model Design award to develop or enhance a comprehensive State Health Care Innovation Plan. Up to 12 states will be chosen for state-sponsored Model Testing awards ($700 million available) and up to 15 states will be chosen for state-sponsored Model Design work ($30 million available).
Examples of ongoing state-led health care innovations include development of advanced primary care networks supported by statewide health information technology systems and models that coordinate care seamlessly across providers. The second round of the State Innovation Models will continue to support and advance this good work.
Wednesday, April 2, 2014
WHITE HOUSE RESPONSE TO HOUSE REPUBLICAN BUDGET
FROM: THE WHITE HOUSE
Statement by the Press Secretary on the House Republican Budget
To build real, lasting economic security for the middle class, the President and Democrats in Congress have a plan to grow our economy from the middle out, not the top down, and create more opportunities for every hardworking American to get ahead. Unfortunately, Republicans in Congress do not have a plan that works for the middle class and the House Republican Budget is the same old top-down approach. Because of a stubborn unwillingness to cut the deficit in a balanced way by closing tax loopholes for the wealthy and well connected, the House Republican Budget would slow the economy, stack the deck against the middle class, and threaten the guaranteed benefits seniors have paid for and earned.
The House Republican Budget would raise taxes on middle class families with children by an average of at least $2,000 in order to cut taxes for households with incomes over $1 million. It would force deep cuts to investments in our roads and bridges, scientific research to cure diseases like Alzheimer’s and at every level of education from early childhood to community college. It would end Medicare as we know it, turning it into a voucher program and risking a death spiral in traditional Medicare. Instead of ensuring that Americans earn a fair wage for a hard day’s work and lifting millions of people out of poverty, the House Republican approach undermines Americans working hard to support their families by slashing food stamps and Medicaid. And rather than expanding health coverage for all Americans and making it more affordable, it would repeal the Affordable Care Act, raising health care costs on families and businesses and eliminating coverage for the 3 million young adults who have gained coverage by staying on their parent’s plan, the millions of people who have signed up for private insurance plans through the Marketplaces, and millions more who can continue to gain coverage through Medicaid.
The House Republican Budget stands in stark contrast to the President’s Budget, which would accelerate economic growth and expand opportunity for all hardworking Americans, while continuing to cut the deficit in a balanced way. The President has put forward a Budget that rewards hard work with fair wages, equips all children with a high-quality education to prepare them for a good job, puts a secure retirement within reach, and ensures health care is affordable and reliable, while at the same time asking the wealthiest to pay their fair share and making tough cuts to programs we can’t afford. And by paying for new investments and tackling our true fiscal challenges, the President’s Budget builds on the progress we’ve already made to cut the deficit by more than half since 2009 and cuts the deficit as a share of the economy to 1.6 percent by 2024. It also stabilizes the debt as a share of the economy by 2015 and puts it on a declining path after that.
Budgets are about choices and values. House Republicans have chosen to protect tax breaks for the wealthiest rather than create opportunities for middle class families to get ahead. The President believes that is the wrong approach and that we should instead be making smart investments necessary to create jobs, grow our economy, and expand opportunity, while still cutting the deficit in a balanced way and securing our nation’s future.
Thursday, February 20, 2014
GOVERNMENT INTERVENES IN TENET HEALTHCARE LAWSUIT
FROM: U.S. JUSTICE DEPARTMENT
Wednesday, February 19, 2014
Government Intervenes in Lawsuit Against Tenet Healthcare Corp. and Georgia Hospital Owned by Health Management Associates Inc. Alleging Payment of Kickbacks
The government has intervened in a False Claims Act lawsuit against Tenet Healthcare Corp. (Tenet) and four of its hospitals in Georgia and South Carolina, as well as a hospital in Monroe, Ga., owned by Health Management Associates Inc. (HMA), alleging that the hospitals paid kickbacks to obstetric clinics serving primarily undocumented Hispanic women in return for referral of those patients for labor and delivery at the hospitals. The hospitals then billed the Medicaid programs in Georgia and South Carolina for the services provided to the referred patients and, in some instances, also obtained additional Medicare reimbursement based on the influx of low-income patients. Tenet and HMA are two of the largest owner/operators of hospitals in the United States. HMA was acquired by Community Health Systems last month. The government also is intervening against the clinics and related entities known as Hispanic Medical Management d/b/a Clinica de la Mama.
“The Department of Justice is committed to ensuring that health care providers who pay kickbacks in return for patient referrals are held accountable,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “Schemes such as this one corrupt the health care system and take advantage of vulnerable patients.”
“My office has made the investigation of health care fraud a priority,” said U.S. Attorney for the Middle District of Georgia Michael J. Moore. “In a time when too many people were struggling to get health care for themselves and their children, Tenet and these hospitals plundered a system set up for those truly in need. This kind of scheme drives up costs for everyone, not just the vulnerable patients and groups like those targeted in this case.”
The lawsuit alleges that four Tenet hospitals, Atlanta Medical Center, North Fulton Regional Hospital, Spalding Regional Hospital and Hilton Head Hospital in South Carolina, and one HMA facility, Walton Regional Medical Center (since renamed Clearview Regional Medical Center), paid kickbacks to Hispanic Medical Management d/b/a Clinica de la Mama (Clinica) and related entities in return for Clinica’s agreement to send pregnant women to their facilities for deliveries paid for by Medicaid, in violation of the federal Medicare and Medicaid Anti-Kickback Statute. The kickbacks were disguised as payments for a variety of services allegedly provided by Clinica.
The Anti-Kickback Statute prohibits offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid and other federally funded programs. The Anti-Kickback Statute is intended to ensure that a physician’s medical judgment is not compromised by improper financial incentives and is instead based on the best interests of the patient.
“Investigations such as these are a high priority for the FBI, and we are determined to hold accountable providers that enrich themselves at the expense of government programs and damage the public trust,” said FBI Assistant Director Ronald T. Hosko. “The FBI is dedicated to preventing and combating all forms of health care fraud; working with federal, state and local partners to effectively resolve allegations and engaging with the public to identify potential schemes.”
The lawsuit was filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue on behalf of the government when they believe that defendants submitted false claims for government funds and to receive a share of any recovery. The False Claims Act also permits the government to intervene in such lawsuits, as it has done in this case. The lawsuit is pending in the Middle District of Georgia .
The government’s intervention in this matter illustrates its emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $19 billion through False Claims Act cases, with more than $13.4 billion of that amount recovered in cases involving fraud against federal health care programs.
These matters were investigated by the Commercial Litigation Branch of the Justice Department’s Civil Division, the Fraud Section of the department’s Criminal Division, the U.S. Attorney’s Offices for the Middle and Northern Districts of Georgia, the Department of Health and Human Services Office of Inspector General, the Federal Bureau of Investigation and the Office of the Attorney General for the State of Georgia.
The case is captioned United States ex rel. Williams v. Health Mgmt. Assocs. Inc., Tenet Healthcare, et al., No. 3:09-CV-130 (M.D. Ga.).
The claims asserted against Tenet, the HMA facility and Clinica are allegations only, and there has been no determination of liability.
Wednesday, February 19, 2014
Government Intervenes in Lawsuit Against Tenet Healthcare Corp. and Georgia Hospital Owned by Health Management Associates Inc. Alleging Payment of Kickbacks
The government has intervened in a False Claims Act lawsuit against Tenet Healthcare Corp. (Tenet) and four of its hospitals in Georgia and South Carolina, as well as a hospital in Monroe, Ga., owned by Health Management Associates Inc. (HMA), alleging that the hospitals paid kickbacks to obstetric clinics serving primarily undocumented Hispanic women in return for referral of those patients for labor and delivery at the hospitals. The hospitals then billed the Medicaid programs in Georgia and South Carolina for the services provided to the referred patients and, in some instances, also obtained additional Medicare reimbursement based on the influx of low-income patients. Tenet and HMA are two of the largest owner/operators of hospitals in the United States. HMA was acquired by Community Health Systems last month. The government also is intervening against the clinics and related entities known as Hispanic Medical Management d/b/a Clinica de la Mama.
“The Department of Justice is committed to ensuring that health care providers who pay kickbacks in return for patient referrals are held accountable,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “Schemes such as this one corrupt the health care system and take advantage of vulnerable patients.”
“My office has made the investigation of health care fraud a priority,” said U.S. Attorney for the Middle District of Georgia Michael J. Moore. “In a time when too many people were struggling to get health care for themselves and their children, Tenet and these hospitals plundered a system set up for those truly in need. This kind of scheme drives up costs for everyone, not just the vulnerable patients and groups like those targeted in this case.”
The lawsuit alleges that four Tenet hospitals, Atlanta Medical Center, North Fulton Regional Hospital, Spalding Regional Hospital and Hilton Head Hospital in South Carolina, and one HMA facility, Walton Regional Medical Center (since renamed Clearview Regional Medical Center), paid kickbacks to Hispanic Medical Management d/b/a Clinica de la Mama (Clinica) and related entities in return for Clinica’s agreement to send pregnant women to their facilities for deliveries paid for by Medicaid, in violation of the federal Medicare and Medicaid Anti-Kickback Statute. The kickbacks were disguised as payments for a variety of services allegedly provided by Clinica.
The Anti-Kickback Statute prohibits offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid and other federally funded programs. The Anti-Kickback Statute is intended to ensure that a physician’s medical judgment is not compromised by improper financial incentives and is instead based on the best interests of the patient.
“Investigations such as these are a high priority for the FBI, and we are determined to hold accountable providers that enrich themselves at the expense of government programs and damage the public trust,” said FBI Assistant Director Ronald T. Hosko. “The FBI is dedicated to preventing and combating all forms of health care fraud; working with federal, state and local partners to effectively resolve allegations and engaging with the public to identify potential schemes.”
The lawsuit was filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue on behalf of the government when they believe that defendants submitted false claims for government funds and to receive a share of any recovery. The False Claims Act also permits the government to intervene in such lawsuits, as it has done in this case. The lawsuit is pending in the Middle District of Georgia .
The government’s intervention in this matter illustrates its emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $19 billion through False Claims Act cases, with more than $13.4 billion of that amount recovered in cases involving fraud against federal health care programs.
These matters were investigated by the Commercial Litigation Branch of the Justice Department’s Civil Division, the Fraud Section of the department’s Criminal Division, the U.S. Attorney’s Offices for the Middle and Northern Districts of Georgia, the Department of Health and Human Services Office of Inspector General, the Federal Bureau of Investigation and the Office of the Attorney General for the State of Georgia.
The case is captioned United States ex rel. Williams v. Health Mgmt. Assocs. Inc., Tenet Healthcare, et al., No. 3:09-CV-130 (M.D. Ga.).
The claims asserted against Tenet, the HMA facility and Clinica are allegations only, and there has been no determination of liability.
Tuesday, February 11, 2014
HHS SAYS "95% OF UNINSURED LATINOS COULD QUALIFY FOR LOWER COSTS ON HEALTH CARE COVERAGE"
FROM: HEALTH AND HUMAN SERVICES DEPARTMENT
Eight in 10 uninsured Latinos may qualify for Medicaid, CHIP or lower costs on monthly premiums in the Health Insurance Marketplace
95 percent of uninsured Latinos could qualify for lower costs on coverage if all states expanded Medicaid
A new report issued today by the Department of Health and Human Services (HHS) finds that that nearly 8 in 10 uninsured Latinos may qualify for Medicaid, the Children’s Health Insurance Program (CHIP), or lower costs on monthly premiums through the Health Insurance Marketplace. If all states took advantage of new opportunities to expand Medicaid coverage under the Affordable Care Act, 95 percent of uninsured Latinos might qualify for Medicaid, the Children’s Health Insurance Program (CHIP), or tax credits to help with the cost of premiums in the Marketplace.
“The health care law addresses longstanding inequalities that have affected minority communities across the nation, including lack of access to affordable health insurance coverage,” said Health and Human Services Secretary Kathleen Sebelius. “Thanks to the Affordable Care Act, 10.2 million uninsured Latinos have the opportunity to purchase quality, affordable coverage through the Marketplace, and as many as 8 million of those could get a break on costs.”
According to today’s report, 1 in 4 uninsured individuals who are eligible for the Marketplace nationwide are Latino (10.2 million out of 41.3 million individuals). The majority (62 percent) live in California, Texas, and Florida; about half (4.6 million or 46 percent) are between the ages of 18 and 35.
Among those Latinos who are eligible for Marketplace coverage nationwide, about 3.9 million may be eligible for lower costs on monthly premiums, and 4.2 million may be eligible for Medicaid or CHIP. The report details uninsurance rates by state and provides several examples of what premiums might look like for Latinos living in major metropolitan areas. For example, a 27 year old with an income of $25,000 living in Miami, Florida could pay as little as $87 for a bronze plan. In Houston, Texas he or she could pay as little as $99 after factoring in premium tax credits.
The majority (63 percent) of uninsured Hispanic Americans who are eligible for coverage in the Marketplace either speak English as a first language, or “very well” as a second language. About one-third (37 percent) rely on Spanish, and 27 percent live in a household without an English-speaking adult present. This is why from the beginning HHS’s outreach has been a bilingual effort. Since October 1, the diverse Latino community has had access to multiple resources to help with enrollment in the Marketplace, including applying by phone with trained call center staff offering bilingual help, or in person with trained specialists in local communities.
Latinos can enroll in Spanish through CuidadodeSalud.gov where consumers can create accounts, complete an online application, and shop for health plans that fit their budget and needs.
Eight in 10 uninsured Latinos may qualify for Medicaid, CHIP or lower costs on monthly premiums in the Health Insurance Marketplace
95 percent of uninsured Latinos could qualify for lower costs on coverage if all states expanded Medicaid
A new report issued today by the Department of Health and Human Services (HHS) finds that that nearly 8 in 10 uninsured Latinos may qualify for Medicaid, the Children’s Health Insurance Program (CHIP), or lower costs on monthly premiums through the Health Insurance Marketplace. If all states took advantage of new opportunities to expand Medicaid coverage under the Affordable Care Act, 95 percent of uninsured Latinos might qualify for Medicaid, the Children’s Health Insurance Program (CHIP), or tax credits to help with the cost of premiums in the Marketplace.
“The health care law addresses longstanding inequalities that have affected minority communities across the nation, including lack of access to affordable health insurance coverage,” said Health and Human Services Secretary Kathleen Sebelius. “Thanks to the Affordable Care Act, 10.2 million uninsured Latinos have the opportunity to purchase quality, affordable coverage through the Marketplace, and as many as 8 million of those could get a break on costs.”
According to today’s report, 1 in 4 uninsured individuals who are eligible for the Marketplace nationwide are Latino (10.2 million out of 41.3 million individuals). The majority (62 percent) live in California, Texas, and Florida; about half (4.6 million or 46 percent) are between the ages of 18 and 35.
Among those Latinos who are eligible for Marketplace coverage nationwide, about 3.9 million may be eligible for lower costs on monthly premiums, and 4.2 million may be eligible for Medicaid or CHIP. The report details uninsurance rates by state and provides several examples of what premiums might look like for Latinos living in major metropolitan areas. For example, a 27 year old with an income of $25,000 living in Miami, Florida could pay as little as $87 for a bronze plan. In Houston, Texas he or she could pay as little as $99 after factoring in premium tax credits.
The majority (63 percent) of uninsured Hispanic Americans who are eligible for coverage in the Marketplace either speak English as a first language, or “very well” as a second language. About one-third (37 percent) rely on Spanish, and 27 percent live in a household without an English-speaking adult present. This is why from the beginning HHS’s outreach has been a bilingual effort. Since October 1, the diverse Latino community has had access to multiple resources to help with enrollment in the Marketplace, including applying by phone with trained call center staff offering bilingual help, or in person with trained specialists in local communities.
Latinos can enroll in Spanish through CuidadodeSalud.gov where consumers can create accounts, complete an online application, and shop for health plans that fit their budget and needs.
Saturday, January 25, 2014
TWO ORTHOPEDIC CLINICS TO PAY $1.85 MILLION TO SETTLE FALSE CLAIMS ACT ALLEGATIONS
FROM: JUSTICE DEPARTMENT
Friday, January 24, 2014
Tennessee and Virginia Orthopedic Clinics to Pay $1.85 Million to Settle Allegations of Billing Medicare for Reimported Products
Two orthopedic clinics will pay a combined $1.85 million to resolve state and federal False Claims Act allegations that they knowingly billed state and federal health care programs for reimported osteoarthritis medications, known as viscosupplements, the Department of Justice announced today. Tennessee Orthopaedic Clinics P.C., headquartered in Knoxville, Tenn., will pay $1.3 million, and Appalachian Orthopaedic Clinics P.C., headquartered in Kingsport, Tenn., will pay $550,000.
“The Department of Justice will not tolerate the conduct of companies that impermissibly shift risks onto patients in order to increase their own profits,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “The department is committed to maintaining the integrity of the health care system, ensuring that patients receive drugs and devices that are safe and effective and taking action against companies that take chances with the health of consumers so as to improve their own bottom lines.”
Viscosupplements, such as Synvisc and Orthovisc, are injections approved by the Food and Drug Administration for the treatment of osteoarthritis pain in the knee. Viscosupplements are reimbursed by Medicare, Medicaid and other federal health care programs at a set rate based on the average sales price of the domestic product. The government contended that the clinics knowingly purchased deeply discounted viscosupplements that were reimported from foreign countries and billed them to state and federal health care programs in order to profit from the reimbursement system, when such reimported viscosupplements were not reimbursable by those programs. Allegedly, the reimported product included labeling in foreign languages and in English for additional uses not approved in the United States, which demonstrated that the product was reimported. Moreover, because the product was reimported, the government alleged there was no manufacturer assurance that it had not been tampered with or that it was stored appropriately.
“This scheme is yet another example of illegal actions by health care providers to profit from drugs imported into the United States,” said U.S. Attorney for the Eastern District of Tennessee William C. Killian. “Medicare and FDA requirements are designed to prevent potential harm to patients. Noncompliance with the law to increase profit at the risk of patients will be pursued by the Department of Justice.”
“Attempts to increase profits by circumventing the law will not be tolerated,” said Special Agent in Charge of the U.S. Department of Health and Human Services Office of Inspector General in Atlanta Derrick L. Jackson. “Health care providers buying cut-rate, cheap drugs from foreign sources will end up paying a steep price.”
The allegations resolved by the settlement were first raised in a lawsuit filed against the clinics under the qui tam, or whistleblower, provisions of the False Claims Act by Douglas Estey, a physician’s assistant who was occasionally paid by Genzyme Corp. to speak to medical providers about the use of Synvisc. The Act allows private citizens with knowledge of fraud to bring civil actions on behalf of the government and to share in any recovery. Estey will receive $323,750.
The government’s investigation was a coordinated effort by the Civil Division of the Department of Justice, the U.S. Attorney’s Office for the Eastern District of Tennessee, the Department of Health and Human Services Office of Inspector General and Office of General Counsel, the Food and Drug Administration Office of Criminal Investigations and Office of Chief Counsel, the Federal Bureau of Investigation and the Tennessee Bureau of Investigation.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $17.1 billion through False Claims Act cases, with more than $12.2 billion of that amount recovered in cases involving fraud against federal health care programs.
The case is captioned United States ex rel. Estey v. Tennessee Orthopaedic Clinics P.C., Appalachian Orthopaedic Associates P.C. and Appalachian Orthopaedic Partners LLC, Docket No. 3:12-cv-85 Varlan/Guyton. The claims settled by these agreements are allegations only; there have been no determinations of liability.
Friday, January 24, 2014
Tennessee and Virginia Orthopedic Clinics to Pay $1.85 Million to Settle Allegations of Billing Medicare for Reimported Products
Two orthopedic clinics will pay a combined $1.85 million to resolve state and federal False Claims Act allegations that they knowingly billed state and federal health care programs for reimported osteoarthritis medications, known as viscosupplements, the Department of Justice announced today. Tennessee Orthopaedic Clinics P.C., headquartered in Knoxville, Tenn., will pay $1.3 million, and Appalachian Orthopaedic Clinics P.C., headquartered in Kingsport, Tenn., will pay $550,000.
“The Department of Justice will not tolerate the conduct of companies that impermissibly shift risks onto patients in order to increase their own profits,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “The department is committed to maintaining the integrity of the health care system, ensuring that patients receive drugs and devices that are safe and effective and taking action against companies that take chances with the health of consumers so as to improve their own bottom lines.”
Viscosupplements, such as Synvisc and Orthovisc, are injections approved by the Food and Drug Administration for the treatment of osteoarthritis pain in the knee. Viscosupplements are reimbursed by Medicare, Medicaid and other federal health care programs at a set rate based on the average sales price of the domestic product. The government contended that the clinics knowingly purchased deeply discounted viscosupplements that were reimported from foreign countries and billed them to state and federal health care programs in order to profit from the reimbursement system, when such reimported viscosupplements were not reimbursable by those programs. Allegedly, the reimported product included labeling in foreign languages and in English for additional uses not approved in the United States, which demonstrated that the product was reimported. Moreover, because the product was reimported, the government alleged there was no manufacturer assurance that it had not been tampered with or that it was stored appropriately.
“This scheme is yet another example of illegal actions by health care providers to profit from drugs imported into the United States,” said U.S. Attorney for the Eastern District of Tennessee William C. Killian. “Medicare and FDA requirements are designed to prevent potential harm to patients. Noncompliance with the law to increase profit at the risk of patients will be pursued by the Department of Justice.”
“Attempts to increase profits by circumventing the law will not be tolerated,” said Special Agent in Charge of the U.S. Department of Health and Human Services Office of Inspector General in Atlanta Derrick L. Jackson. “Health care providers buying cut-rate, cheap drugs from foreign sources will end up paying a steep price.”
The allegations resolved by the settlement were first raised in a lawsuit filed against the clinics under the qui tam, or whistleblower, provisions of the False Claims Act by Douglas Estey, a physician’s assistant who was occasionally paid by Genzyme Corp. to speak to medical providers about the use of Synvisc. The Act allows private citizens with knowledge of fraud to bring civil actions on behalf of the government and to share in any recovery. Estey will receive $323,750.
The government’s investigation was a coordinated effort by the Civil Division of the Department of Justice, the U.S. Attorney’s Office for the Eastern District of Tennessee, the Department of Health and Human Services Office of Inspector General and Office of General Counsel, the Food and Drug Administration Office of Criminal Investigations and Office of Chief Counsel, the Federal Bureau of Investigation and the Tennessee Bureau of Investigation.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $17.1 billion through False Claims Act cases, with more than $12.2 billion of that amount recovered in cases involving fraud against federal health care programs.
The case is captioned United States ex rel. Estey v. Tennessee Orthopaedic Clinics P.C., Appalachian Orthopaedic Associates P.C. and Appalachian Orthopaedic Partners LLC, Docket No. 3:12-cv-85 Varlan/Guyton. The claims settled by these agreements are allegations only; there have been no determinations of liability.
Saturday, January 11, 2014
HHS WORKS ON LIVING OPTIONS FOR OLDER PEOPLE WITH DISABILITIES
FROM: HEALTH AND HUMAN SERVICES
HHS strengthens community living options for older Americans and people with disabilities
The Centers for Medicare & Medicaid Services (CMS) issued a final rule today to ensure that Medicaid’s home and community-based services programs provide full access to the benefits of community living and offer services in the most integrated settings. The rule, as part of the Affordable Care Act, supports the Department of Health and Human Services’ Community Living Initiative. The initiative was launched in 2009 to develop and implement innovative strategies to increase opportunities for Americans with disabilities and older adults to enjoy meaningful community living.
Under the final rule, Medicaid programs will support home and community-based settings that serve as an alternative to institutional care and that take into account the quality of individuals’ experiences. The final rule includes a transitional period for states to ensure that their programs meet the home and community-based services settings requirements. Technical assistance will also be available for states.
“People with disabilities and older adults have a right to live, work, and participate in the greater community. HHS, through its Community Living Initiative, has been expanding and improving the community services necessary to make this a reality,” said HHS Secretary Kathleen Sebelius. “Today’s announcement will help ensure that all people participating in Medicaid home and community-based services programs have full access to the benefits of community living.”
In addition to defining home and community-based settings, the final rule implements the Section 1915(i) home and community-based services State Plan option. This includes new flexibility provided by the Affordable Care Act that gives states additional options for expanding home and community-based services and to target services to specific populations. It also amends the 1915(c) home and community-based services waiver program to add new person-centered planning requirements, allow states to combine multiple target populations in one waiver, and streamlines waiver administration.
HHS strengthens community living options for older Americans and people with disabilities
The Centers for Medicare & Medicaid Services (CMS) issued a final rule today to ensure that Medicaid’s home and community-based services programs provide full access to the benefits of community living and offer services in the most integrated settings. The rule, as part of the Affordable Care Act, supports the Department of Health and Human Services’ Community Living Initiative. The initiative was launched in 2009 to develop and implement innovative strategies to increase opportunities for Americans with disabilities and older adults to enjoy meaningful community living.
Under the final rule, Medicaid programs will support home and community-based settings that serve as an alternative to institutional care and that take into account the quality of individuals’ experiences. The final rule includes a transitional period for states to ensure that their programs meet the home and community-based services settings requirements. Technical assistance will also be available for states.
“People with disabilities and older adults have a right to live, work, and participate in the greater community. HHS, through its Community Living Initiative, has been expanding and improving the community services necessary to make this a reality,” said HHS Secretary Kathleen Sebelius. “Today’s announcement will help ensure that all people participating in Medicaid home and community-based services programs have full access to the benefits of community living.”
In addition to defining home and community-based settings, the final rule implements the Section 1915(i) home and community-based services State Plan option. This includes new flexibility provided by the Affordable Care Act that gives states additional options for expanding home and community-based services and to target services to specific populations. It also amends the 1915(c) home and community-based services waiver program to add new person-centered planning requirements, allow states to combine multiple target populations in one waiver, and streamlines waiver administration.
Monday, December 23, 2013
JUSTICE ANNOUNCES RECOVERY OF $3.8 BILLION FROM FALSE CLAIM ACT CASES IN FISCAL 2013
FROM: U.S. JUSTICE DEPARTMENT
Friday, December 20, 2013
Justice Department Recovers $3.8 Billion from False Claims Act Cases in Fiscal Year 2013
Second Largest Annual Recovery in History Whistleblower Lawsuits Soar to 752
The Justice Department secured $3. 8 billion in settlements and judgments from civil cases involving fraud against the government in the fiscal year ending Sept. 30, 2013, Assistant Attorney General for the Civil Division Stuart F. Delery announced today. This dollar amount, which is the second largest annual recovery of its type in history, brings total recoveries under the False Claims Act since January 2009 to $ 17 billion – nearly half the total recoveries since the Act was amended 27 years ago in 1986.
The Justice Department’s fiscal year 2013 efforts recovered more than $3 billion for the fourth year in a row and are surpassed only by last year’s nearly $5 billion in recoveries. As in previous years, the largest recoveries related to health care fraud, which reached $2. 6 billion. Procurement fraud (related primarily to defense contracts) accounted for another $ 890 million – a record in that area.
“It has been another banner year for civil fraud recoveries, but more importantly, it has been a great year for the taxpayer and for the millions of Americans, state agencies and organizations that benefit from government programs and contracts,” said Assistant Attorney General Delery. “The $3. 8 billion in federal False Claims Act recoveries in fiscal year 2013, plus another $443 million in recoveries for state Medicaid programs, restores scarce taxpayer dollars to federal and state governments. The government’s success in these cases is also a strong deterrent to others who would misuse public funds, which means government programs designed to keep us safer, healthier and economically more prosperous can do so without the corrosive effects of fraud and false claims.”
The False Claims Act is the government’s primary civil remedy to redress false claims for government funds and property under government contracts, including national security and defense contracts, as well as under government programs as varied as Medicare, veterans benefits, federally insured loans and mortgages, transportation and research grants, agricultural supports, school lunches and disaster assistance. In 1986, Congress strengthened the Act by amending it to increase incentives for whistleblowers to file lawsuits on behalf of the government, which has led to more investigations and greater recoveries.
Most false claims actions are filed under the Act’s whistleblower, or qui tam, provisions, which allow private citizens to file lawsuits alleging false claims on behalf of the government. If the government prevails in the action, the whistleblower, known as a relator, receives up to 30 perc ent of the recovery. The number of qui tam suits filed in fiscal year 2013 soared to 752 –100 more than the record set the previous fiscal year. Recoveries in qui tam cases during fiscal year 2013 totaled $2. 9 billion , with whistleblowers recovering $345 million.
Health Care Fraud
The $2. 6 billion in health care fraud recoveries in fiscal year 2013 marks four straight years the department has recovered more than $2 billion in cases involving health care fraud. This steady, significant and continuing success can be attributed to the high priority the Obama Administration has placed on fighting health care fraud. In 2009, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced the creation of an interagency task force, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to increase coordination and optimize criminal and civil enforcement. This coordination has yielded historic results: From January 2009 through the end of the 2013 fiscal year, the department used the False Claims Act to recover $12 .1 billion in federal health care dollars. Most of these recoveries relate to fraud against Medicare and Medicaid. Additional information on the government’s efforts in this area is available at StopMedicareFraud.gov, a webpage jointly established by the Departments of Justice and Health and Human Services.
Some of the largest recoveries this past fiscal year involved allegations of fraud and false claims in the pharmaceutical and medical device industries. Of the $2. 6 billion in federal health care fraud recoveries, $1.8 billion were from alleged false claims for drugs and medical devices under federally insured health programs that, in addition to Medicare and Medicaid, include TRICARE, which provides benefits for military personnel and their families, veterans’ health care programs and the Federal Employees Health Benefits Program. The department recovered an additional $443 million for state Medicaid programs.
Many of these settlements involved allegations that pharmaceutical manufacturers improperly promoted their drugs for uses not approved by the Food and Drug Administration (FDA) – a practice known as “off-label marketing.” For example, drug manufacturer Abbott Laboratories Inc. paid $1.5 billion to resolve allegations that it illegally promoted the drug Depakote to treat agitation and aggression in elderly dementia patients and schizophrenia when neither of these uses was approved as safe and effective by the FDA. This landmark $1.5 billion settlement included $575 million in federal civil recoveries, $225 million in state civil recoveries and nearly $700 million in criminal fines and forfeitures. In another major pharmaceutical case, biotech giant Amgen Inc. paid the government $762 million, including $598.5 million in False Claims Act recoveries, to settle allegations that included its illegal promotion of Aranesp, a drug used to treat anemia, in doses not approved by the FDA and for off-label use to treat non-anemia-related conditions. For details, see Abbott, Abbott sentencing, and Amgen.
The department also settled allegations relating to the manufacture and distribution of adulterated drugs. For example, generic drug manufacturer Ranbaxy USA Inc. paid $505 million to settle allegations of false claims to federal and state health care programs for adulterated drugs distributed from its facilities in India. The settlement included $237 million in federal civil claims, $118 million in state civil claims and $150 million in criminal fines and forfeitures. For details, see Ranbaxy.
Adding to its successes under the False Claims Act, the Civil Division’s Consumer Protection Branch, together with U.S. Attorneys across the country, obtained 16 criminal convictions and more than $1. 3 billion in criminal fines, forfeitures and disgorgement under the Federal Food, Drug and Cosmetic Act (FDCA). The FDCA protects the health and safety of the public by ensuring, among other things, that drugs intended for use in humans are safe and effective for their intended uses and that the labeling of such drugs bears true, complete and accurate information.
In other areas of health care fraud, the department obtained a $237 million judgment against South Carolina-based Tuomey Healthcare System Inc., after a four-week trial, for violating the Stark Law and the False Claims Act. The Stark Law prohibits hospitals from submitting claims to Medicare for patients referred to the hospital by physicians who have a prohibited financial relationship with the hospital. Tuomey’s appeal of the $237 million judgment is pending. If the judgment is affirmed on appeal, this will be the largest judgment in the history of the Stark Law. For the court’s opinion, see Tuomey.
The department also recovered $26.3 million in a settlement with Steven J. Wasserman M.D., a dermatologist practicing in Florida, to resolve allegations that he entered into an illegal kickback arrangement with Tampa Pathology Laboratory that resulted in increased claims to Medicare. Tampa Pathology Laboratory previously paid the government $950,000 for its role in the alleged scheme. The $26.3 million settlement is one of the largest with an individual in the history of the False Claims Act. For details, see Wasserman.
Procurement Fraud
Fiscal year 2013 was a record year for procurement fraud matters. The department secured more than $887 million in settlements and judgments based on allegations of false claims and corruption involving government contracts. Prominent among these successes was the department’s $664 million judgment against Connecticut-based defense contractor United Technologies Corp. (UTC). A federal court found UTC liable for making false statements to the Air Force in negotiating the price of a contract for fighter jet engines. In 2004, the department had won a smaller judgment after a three-month trial. Both sides appealed, but the government’s arguments prevailed, resulting in the case being returned to the trial court to reassess damages. The $664 million judgment, which UTC has appealed, is the largest judgment in the history of the False Claims Act and, if the appellate court affirms, will be the largest procurement recovery in history. For details, see UTC.
The department also settled allegations of false claims with two companies in connection with their contracts with the General Services Administration (GSA) to market their products through the Multiple Award Schedule (MAS) program. To be awarded a MAS contract, and thereby gain access to the broad government marketplace, contractors must provide GSA with complete, accurate and current information about their commercial sales practices, including discounts afforded to their commercial customers. The government alleged that W.W. Grainger Inc., a national hardware distributor headquartered in Illinois, and Ohio-based RPM International Inc. and its subsidiary, Tremco Inc., a roofing supplies and services firm, failed to disclose discounts given to their commercial customers, which resulted in government customers paying higher prices. The department recovered $70 million from W.W. Grainger in a settlement that also included allegations relating to a U.S. Postal Services contract and $61 million from RPM International Inc. and Tremco. For details, see Grainger, RPM/Tremco.
Other Fraud Recoveries
A $45 million settlement with Japan-based Toyo Ink S.C. Holdings Co. Ltd. and its Japanese and United States affiliates (collectively Toyo) demonstrates the breadth of cases the department pursues. This settlement resolved allegations that Toyo misrepresented the country of origin on documents presented to the Department of Homeland Security’s U.S. Customs and Border Protection to evade antidumping and countervailing duties on imports of the colorant carbazole violet pigment into the United States. These duties protect U.S. businesses by offsetting unfair foreign pricing and foreign government subsidies. For details, see Toyo.
The False Claims Act also is used to redress grant fraud. In a significant case involving a grant from the Department of Education, Education Holdings Inc. (formerly The Princeton Review Inc.) paid $10 million to resolve allegations that the company fabricated attendance records for thousands of hours of afterschool tutoring of students that was funded by the federal grant. For details, see Education Holdings.
Recoveries in Whistleblower Suits
Of the $3. 8 billion the department recovered in fiscal year 2013, $2. 9 billion related to lawsuits filed under the qui tam provisions of the False Claims Act. During the same period, the department paid out more than $345 million to the courageous individuals who exposed fraud and false claims by filing a qui tam complaint. (The average share paid to whistleblowers in fiscal year 2013 cannot be determined from these numbers because the awards paid to whistleblowers in one fiscal year do not always coincide with the fiscal year in which the case was resolved, and the fiscal year’s recoveries may include amounts to settle allegations outside the whistleblower’s complaint.)
Whistleblower lawsuits were in the range of three to four hundred per year from 2000 to 2009, when they began their climb from 433 lawsuits in fiscal year 2009 to 752 lawsuits in fiscal year 2013. Due to the complexity of fraud investigations generally, the outcomes of many of the qui tam cases filed this past fiscal year are not yet known, but the growing number of lawsuits filed since 2009 have led to increased recoveries. Qui tam recoveries exceeded $2 billion for the first time in fiscal year 2010 and have continued to exceed that amount every year since. Qui tam recoveries this past fiscal year bring the department’s totals since January 2009 to $13.4 billion. During the same period, the department paid out $1.98 billion in whistleblower awards.
“These recoveries would not have been possible without the brave contributions made by ordinary men and women who made extraordinary sacrifices to expose fraud and corruption in government programs,” said Assistant Attorney General Delery. “We are also grateful to Congress and its continued support of strengthening the False Claims Act, including its qui tam provisions, giving the department the tools necessary to pursue false claims.”
In 1986, Senator Charles Grassley and Representative Howard Berman led successful efforts in Congress to amend the False Claims Act to, among other things, encourage whistleblowers to come forward with allegations of fraud. In 2009, Senator Patrick J. Leahy, along with Senator Grassley and Representative Berman, championed the Fraud Enforcement and Recovery Act of 2009, which made additional improvements to the False Claims Act and other fraud statutes. And in 2010, the passage of the Affordable Care Act provided additional inducements and protections for whistleblowers and strengthened the provisions of the federal health care Anti-Kickback Statute.
Assistant Attorney General Delery also expressed his deep appreciation for the dedicated public servants who investigated and pursued these cases. These individuals include attorneys, investigators, auditors and other agency personnel throughout the Justice Department’s Civil Division, the U.S. Attorneys’ Offices, the Departments of Defense and Health and Human Services, the various Offices of Inspector General and the many other federal and state agencies that contributed to the department’s recoveries this past fiscal year.
“The department’s continued success in recovering fraudulent claims for taxpayer money this past fiscal year is a product of the tremendous skill and dedication of the people who worked on these cases and investigations and continue to work hard to protect against the misuse of taxpayer dollars,” said Delery.
Friday, December 20, 2013
Justice Department Recovers $3.8 Billion from False Claims Act Cases in Fiscal Year 2013
Second Largest Annual Recovery in History Whistleblower Lawsuits Soar to 752
The Justice Department secured $3. 8 billion in settlements and judgments from civil cases involving fraud against the government in the fiscal year ending Sept. 30, 2013, Assistant Attorney General for the Civil Division Stuart F. Delery announced today. This dollar amount, which is the second largest annual recovery of its type in history, brings total recoveries under the False Claims Act since January 2009 to $ 17 billion – nearly half the total recoveries since the Act was amended 27 years ago in 1986.
The Justice Department’s fiscal year 2013 efforts recovered more than $3 billion for the fourth year in a row and are surpassed only by last year’s nearly $5 billion in recoveries. As in previous years, the largest recoveries related to health care fraud, which reached $2. 6 billion. Procurement fraud (related primarily to defense contracts) accounted for another $ 890 million – a record in that area.
“It has been another banner year for civil fraud recoveries, but more importantly, it has been a great year for the taxpayer and for the millions of Americans, state agencies and organizations that benefit from government programs and contracts,” said Assistant Attorney General Delery. “The $3. 8 billion in federal False Claims Act recoveries in fiscal year 2013, plus another $443 million in recoveries for state Medicaid programs, restores scarce taxpayer dollars to federal and state governments. The government’s success in these cases is also a strong deterrent to others who would misuse public funds, which means government programs designed to keep us safer, healthier and economically more prosperous can do so without the corrosive effects of fraud and false claims.”
The False Claims Act is the government’s primary civil remedy to redress false claims for government funds and property under government contracts, including national security and defense contracts, as well as under government programs as varied as Medicare, veterans benefits, federally insured loans and mortgages, transportation and research grants, agricultural supports, school lunches and disaster assistance. In 1986, Congress strengthened the Act by amending it to increase incentives for whistleblowers to file lawsuits on behalf of the government, which has led to more investigations and greater recoveries.
Most false claims actions are filed under the Act’s whistleblower, or qui tam, provisions, which allow private citizens to file lawsuits alleging false claims on behalf of the government. If the government prevails in the action, the whistleblower, known as a relator, receives up to 30 perc ent of the recovery. The number of qui tam suits filed in fiscal year 2013 soared to 752 –100 more than the record set the previous fiscal year. Recoveries in qui tam cases during fiscal year 2013 totaled $2. 9 billion , with whistleblowers recovering $345 million.
Health Care Fraud
The $2. 6 billion in health care fraud recoveries in fiscal year 2013 marks four straight years the department has recovered more than $2 billion in cases involving health care fraud. This steady, significant and continuing success can be attributed to the high priority the Obama Administration has placed on fighting health care fraud. In 2009, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced the creation of an interagency task force, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to increase coordination and optimize criminal and civil enforcement. This coordination has yielded historic results: From January 2009 through the end of the 2013 fiscal year, the department used the False Claims Act to recover $12 .1 billion in federal health care dollars. Most of these recoveries relate to fraud against Medicare and Medicaid. Additional information on the government’s efforts in this area is available at StopMedicareFraud.gov, a webpage jointly established by the Departments of Justice and Health and Human Services.
Some of the largest recoveries this past fiscal year involved allegations of fraud and false claims in the pharmaceutical and medical device industries. Of the $2. 6 billion in federal health care fraud recoveries, $1.8 billion were from alleged false claims for drugs and medical devices under federally insured health programs that, in addition to Medicare and Medicaid, include TRICARE, which provides benefits for military personnel and their families, veterans’ health care programs and the Federal Employees Health Benefits Program. The department recovered an additional $443 million for state Medicaid programs.
Many of these settlements involved allegations that pharmaceutical manufacturers improperly promoted their drugs for uses not approved by the Food and Drug Administration (FDA) – a practice known as “off-label marketing.” For example, drug manufacturer Abbott Laboratories Inc. paid $1.5 billion to resolve allegations that it illegally promoted the drug Depakote to treat agitation and aggression in elderly dementia patients and schizophrenia when neither of these uses was approved as safe and effective by the FDA. This landmark $1.5 billion settlement included $575 million in federal civil recoveries, $225 million in state civil recoveries and nearly $700 million in criminal fines and forfeitures. In another major pharmaceutical case, biotech giant Amgen Inc. paid the government $762 million, including $598.5 million in False Claims Act recoveries, to settle allegations that included its illegal promotion of Aranesp, a drug used to treat anemia, in doses not approved by the FDA and for off-label use to treat non-anemia-related conditions. For details, see Abbott, Abbott sentencing, and Amgen.
The department also settled allegations relating to the manufacture and distribution of adulterated drugs. For example, generic drug manufacturer Ranbaxy USA Inc. paid $505 million to settle allegations of false claims to federal and state health care programs for adulterated drugs distributed from its facilities in India. The settlement included $237 million in federal civil claims, $118 million in state civil claims and $150 million in criminal fines and forfeitures. For details, see Ranbaxy.
Adding to its successes under the False Claims Act, the Civil Division’s Consumer Protection Branch, together with U.S. Attorneys across the country, obtained 16 criminal convictions and more than $1. 3 billion in criminal fines, forfeitures and disgorgement under the Federal Food, Drug and Cosmetic Act (FDCA). The FDCA protects the health and safety of the public by ensuring, among other things, that drugs intended for use in humans are safe and effective for their intended uses and that the labeling of such drugs bears true, complete and accurate information.
In other areas of health care fraud, the department obtained a $237 million judgment against South Carolina-based Tuomey Healthcare System Inc., after a four-week trial, for violating the Stark Law and the False Claims Act. The Stark Law prohibits hospitals from submitting claims to Medicare for patients referred to the hospital by physicians who have a prohibited financial relationship with the hospital. Tuomey’s appeal of the $237 million judgment is pending. If the judgment is affirmed on appeal, this will be the largest judgment in the history of the Stark Law. For the court’s opinion, see Tuomey.
The department also recovered $26.3 million in a settlement with Steven J. Wasserman M.D., a dermatologist practicing in Florida, to resolve allegations that he entered into an illegal kickback arrangement with Tampa Pathology Laboratory that resulted in increased claims to Medicare. Tampa Pathology Laboratory previously paid the government $950,000 for its role in the alleged scheme. The $26.3 million settlement is one of the largest with an individual in the history of the False Claims Act. For details, see Wasserman.
Procurement Fraud
Fiscal year 2013 was a record year for procurement fraud matters. The department secured more than $887 million in settlements and judgments based on allegations of false claims and corruption involving government contracts. Prominent among these successes was the department’s $664 million judgment against Connecticut-based defense contractor United Technologies Corp. (UTC). A federal court found UTC liable for making false statements to the Air Force in negotiating the price of a contract for fighter jet engines. In 2004, the department had won a smaller judgment after a three-month trial. Both sides appealed, but the government’s arguments prevailed, resulting in the case being returned to the trial court to reassess damages. The $664 million judgment, which UTC has appealed, is the largest judgment in the history of the False Claims Act and, if the appellate court affirms, will be the largest procurement recovery in history. For details, see UTC.
The department also settled allegations of false claims with two companies in connection with their contracts with the General Services Administration (GSA) to market their products through the Multiple Award Schedule (MAS) program. To be awarded a MAS contract, and thereby gain access to the broad government marketplace, contractors must provide GSA with complete, accurate and current information about their commercial sales practices, including discounts afforded to their commercial customers. The government alleged that W.W. Grainger Inc., a national hardware distributor headquartered in Illinois, and Ohio-based RPM International Inc. and its subsidiary, Tremco Inc., a roofing supplies and services firm, failed to disclose discounts given to their commercial customers, which resulted in government customers paying higher prices. The department recovered $70 million from W.W. Grainger in a settlement that also included allegations relating to a U.S. Postal Services contract and $61 million from RPM International Inc. and Tremco. For details, see Grainger, RPM/Tremco.
Other Fraud Recoveries
A $45 million settlement with Japan-based Toyo Ink S.C. Holdings Co. Ltd. and its Japanese and United States affiliates (collectively Toyo) demonstrates the breadth of cases the department pursues. This settlement resolved allegations that Toyo misrepresented the country of origin on documents presented to the Department of Homeland Security’s U.S. Customs and Border Protection to evade antidumping and countervailing duties on imports of the colorant carbazole violet pigment into the United States. These duties protect U.S. businesses by offsetting unfair foreign pricing and foreign government subsidies. For details, see Toyo.
The False Claims Act also is used to redress grant fraud. In a significant case involving a grant from the Department of Education, Education Holdings Inc. (formerly The Princeton Review Inc.) paid $10 million to resolve allegations that the company fabricated attendance records for thousands of hours of afterschool tutoring of students that was funded by the federal grant. For details, see Education Holdings.
Recoveries in Whistleblower Suits
Of the $3. 8 billion the department recovered in fiscal year 2013, $2. 9 billion related to lawsuits filed under the qui tam provisions of the False Claims Act. During the same period, the department paid out more than $345 million to the courageous individuals who exposed fraud and false claims by filing a qui tam complaint. (The average share paid to whistleblowers in fiscal year 2013 cannot be determined from these numbers because the awards paid to whistleblowers in one fiscal year do not always coincide with the fiscal year in which the case was resolved, and the fiscal year’s recoveries may include amounts to settle allegations outside the whistleblower’s complaint.)
Whistleblower lawsuits were in the range of three to four hundred per year from 2000 to 2009, when they began their climb from 433 lawsuits in fiscal year 2009 to 752 lawsuits in fiscal year 2013. Due to the complexity of fraud investigations generally, the outcomes of many of the qui tam cases filed this past fiscal year are not yet known, but the growing number of lawsuits filed since 2009 have led to increased recoveries. Qui tam recoveries exceeded $2 billion for the first time in fiscal year 2010 and have continued to exceed that amount every year since. Qui tam recoveries this past fiscal year bring the department’s totals since January 2009 to $13.4 billion. During the same period, the department paid out $1.98 billion in whistleblower awards.
“These recoveries would not have been possible without the brave contributions made by ordinary men and women who made extraordinary sacrifices to expose fraud and corruption in government programs,” said Assistant Attorney General Delery. “We are also grateful to Congress and its continued support of strengthening the False Claims Act, including its qui tam provisions, giving the department the tools necessary to pursue false claims.”
In 1986, Senator Charles Grassley and Representative Howard Berman led successful efforts in Congress to amend the False Claims Act to, among other things, encourage whistleblowers to come forward with allegations of fraud. In 2009, Senator Patrick J. Leahy, along with Senator Grassley and Representative Berman, championed the Fraud Enforcement and Recovery Act of 2009, which made additional improvements to the False Claims Act and other fraud statutes. And in 2010, the passage of the Affordable Care Act provided additional inducements and protections for whistleblowers and strengthened the provisions of the federal health care Anti-Kickback Statute.
Assistant Attorney General Delery also expressed his deep appreciation for the dedicated public servants who investigated and pursued these cases. These individuals include attorneys, investigators, auditors and other agency personnel throughout the Justice Department’s Civil Division, the U.S. Attorneys’ Offices, the Departments of Defense and Health and Human Services, the various Offices of Inspector General and the many other federal and state agencies that contributed to the department’s recoveries this past fiscal year.
“The department’s continued success in recovering fraudulent claims for taxpayer money this past fiscal year is a product of the tremendous skill and dedication of the people who worked on these cases and investigations and continue to work hard to protect against the misuse of taxpayer dollars,” said Delery.
Wednesday, November 13, 2013
HHS ANNOUNCES OVER 100,000 AMERICANS SELECTED HEALTH PLANS IN FIRST REPORTING PERIOD
FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
106,185 Americans selected health plans in first reporting period of open enrollment
975,407 customers through the process but have not yet selected a plan; an additional 396,261
assessed or determined eligible for Medicaid or CHIP
Detailing results of the first reporting period (Oct. 1-Nov. 2, 2013) of the Health Insurance Marketplace’s Open Enrollment, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that 106,185 individuals have selected plans from the Marketplace, and another 975,407 have made it through the process by applying and receiving an eligibility determination, but have not yet selected a plan. An additional 396,261 have been determined or assessed eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
“The promise of quality affordable coverage is increasingly becoming reality for this first wave of applicants to the Health Insurance Marketplaces,” Secretary Sebelius said. “There is no doubt the level of interest is strong. We expect enrollment will grow substantially throughout the next five months, mirroring the pattern that Massachusetts experienced. We also expect that the numbers will grow as the website, HealthCare.gov, continues to make steady improvements.”
The following key findings are among many newly available data reported today in an issue brief from HHS that highlights national and state-level enrollment-related information:
502,466 Americans, in just the first month of implementation, are positioned to have health coverage in 2014;
Of those, 106,185 Americans have selected plans from the state and federal Marketplaces; and
396,261 Americans have been determined or assessed eligible for Medicaid or CHIP;
975,407 have made it through the process by applying and receiving an eligibility determination and have not yet selected a plan.
Today’s report includes breakouts of enrollment-related data by state, including each of the 50 states and the District of Columbia. The report groups the states into the Federally-facilitated Marketplace (FFM) (defined as those states where HHS is running the Marketplace or states where HHS is doing so in partnership), and state-based Marketplaces (SBMs). In some cases only a partial SBM dataset was available.
In total, 106,185 Americans selected a Qualified Health Plan (QHP) through the Marketplace during the first reporting period of Open Enrollment. Enrollment figures include those who have selected a plan and have or have not yet paid the first month’s premium. Of the people who have selected a plan, 79,391 (74.8 percent) enrolled though a SBM, while the other 26,794 people (25.2 percent) enrolled through the FFM. Additionally, 396,261 Americans have been assessed or determined eligible for Medicaid or CHIP. SBMs that provided data for the report accounted for 212,865 (53.7 percent) of those determinations, while the FFM accounted for 183,396 (46.3 percent) of them. Forthcoming data will enumerate those who applied directly to a state Medicaid/CHIP office.
The report characterizes past experiences in health insurance enrollment patterns, noting typical low initial enrollment in, for example, the Federal Employees Health Benefits Program Medicare Part D, Massachusetts’ Commonwealth Care, the Children’s Health Insurance Program and the Pre-existing Condition Insurance Plan created under the Affordable Care Act.
The report also addresses Marketplace customer service, outreach and web traffic. It found that there have been an estimated 26,876,527 visitors on the SBM and FFM websites. There have also been an estimated 3,158,436 calls to the SBM and FFM call centers.
106,185 Americans selected health plans in first reporting period of open enrollment
975,407 customers through the process but have not yet selected a plan; an additional 396,261
assessed or determined eligible for Medicaid or CHIP
Detailing results of the first reporting period (Oct. 1-Nov. 2, 2013) of the Health Insurance Marketplace’s Open Enrollment, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that 106,185 individuals have selected plans from the Marketplace, and another 975,407 have made it through the process by applying and receiving an eligibility determination, but have not yet selected a plan. An additional 396,261 have been determined or assessed eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
“The promise of quality affordable coverage is increasingly becoming reality for this first wave of applicants to the Health Insurance Marketplaces,” Secretary Sebelius said. “There is no doubt the level of interest is strong. We expect enrollment will grow substantially throughout the next five months, mirroring the pattern that Massachusetts experienced. We also expect that the numbers will grow as the website, HealthCare.gov, continues to make steady improvements.”
The following key findings are among many newly available data reported today in an issue brief from HHS that highlights national and state-level enrollment-related information:
502,466 Americans, in just the first month of implementation, are positioned to have health coverage in 2014;
Of those, 106,185 Americans have selected plans from the state and federal Marketplaces; and
396,261 Americans have been determined or assessed eligible for Medicaid or CHIP;
975,407 have made it through the process by applying and receiving an eligibility determination and have not yet selected a plan.
Today’s report includes breakouts of enrollment-related data by state, including each of the 50 states and the District of Columbia. The report groups the states into the Federally-facilitated Marketplace (FFM) (defined as those states where HHS is running the Marketplace or states where HHS is doing so in partnership), and state-based Marketplaces (SBMs). In some cases only a partial SBM dataset was available.
In total, 106,185 Americans selected a Qualified Health Plan (QHP) through the Marketplace during the first reporting period of Open Enrollment. Enrollment figures include those who have selected a plan and have or have not yet paid the first month’s premium. Of the people who have selected a plan, 79,391 (74.8 percent) enrolled though a SBM, while the other 26,794 people (25.2 percent) enrolled through the FFM. Additionally, 396,261 Americans have been assessed or determined eligible for Medicaid or CHIP. SBMs that provided data for the report accounted for 212,865 (53.7 percent) of those determinations, while the FFM accounted for 183,396 (46.3 percent) of them. Forthcoming data will enumerate those who applied directly to a state Medicaid/CHIP office.
The report characterizes past experiences in health insurance enrollment patterns, noting typical low initial enrollment in, for example, the Federal Employees Health Benefits Program Medicare Part D, Massachusetts’ Commonwealth Care, the Children’s Health Insurance Program and the Pre-existing Condition Insurance Plan created under the Affordable Care Act.
The report also addresses Marketplace customer service, outreach and web traffic. It found that there have been an estimated 26,876,527 visitors on the SBM and FFM websites. There have also been an estimated 3,158,436 calls to the SBM and FFM call centers.
Friday, November 1, 2013
HHS SAYS HALF OF ELIGIBLE ADULTS COULD GET HEALTH INSURANCE FOR $50 OR LESS
FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Half of single young adults eligible for the Health Insurance Marketplace could get coverage for $50 or less
A new report released today by the Department of Health and Human Services (HHS) shows that nearly half (46 percent) of single young adults who are uninsured and may be eligible for coverage in the Health Insurance Marketplace could get coverage for $50 or less per month.
“The health care law is making health insurance more affordable for young adults,” said HHS Secretary Kathleen Sebelius. “With nearly half of single, Marketplace-eligible uninsured young adults able to get coverage at $50 or less per month, the health care law is delivering the quality, affordable coverage people are looking for.”
Young adults are the age group most likely to be without health insurance. But through the Health Insurance Marketplace, young adults can purchase quality, affordable coverage and get lower costs on monthly premiums through tax credits. Young adults may also be eligible for Medicaid. The amount an individual can save depends on his or her family income and size.
Today’s report examines data from the 34 Federally-facilitated and State Partnership Marketplaces and finds that out of 2.9 million single young adults ages 18 to 34 who may be eligible for coverage in the Marketplace, 1.3 million (46 percent) could purchase a bronze plan for $50 per month or less after tax credits. In the 34 states, a total of 1.9 million young adults, representing nearly 7 in 10 (66 percent) of the potentially Marketplace-eligible uninsured ages 18 to 34, may be able to pay $100 or less for coverage in 2014.
According to the report, an additional 1 million eligible uninsured single young adults may qualify for Medicaid in the states that have opted to expand the program in 2014. Today’s report also shows that if each of the 34 states expanded its Medicaid program, the proportion of young adults who could obtain low-cost coverage would be even greater. If each of the 34 states expanded its Medicaid program, 4.9 million uninsured single young adults would be eligible for Medicaid.
While some states are expanding their Medicaid programs in 2014, other states are not doing so. Under the health care law, states can receive 100 percent federal funding in 2014 to expand their Medicaid programs to cover people with incomes up to 133 percent of the federal poverty level. That’s about $15,800 a year for an individual, or about $32,500 for a family of four.
Half of single young adults eligible for the Health Insurance Marketplace could get coverage for $50 or less
A new report released today by the Department of Health and Human Services (HHS) shows that nearly half (46 percent) of single young adults who are uninsured and may be eligible for coverage in the Health Insurance Marketplace could get coverage for $50 or less per month.
“The health care law is making health insurance more affordable for young adults,” said HHS Secretary Kathleen Sebelius. “With nearly half of single, Marketplace-eligible uninsured young adults able to get coverage at $50 or less per month, the health care law is delivering the quality, affordable coverage people are looking for.”
Young adults are the age group most likely to be without health insurance. But through the Health Insurance Marketplace, young adults can purchase quality, affordable coverage and get lower costs on monthly premiums through tax credits. Young adults may also be eligible for Medicaid. The amount an individual can save depends on his or her family income and size.
Today’s report examines data from the 34 Federally-facilitated and State Partnership Marketplaces and finds that out of 2.9 million single young adults ages 18 to 34 who may be eligible for coverage in the Marketplace, 1.3 million (46 percent) could purchase a bronze plan for $50 per month or less after tax credits. In the 34 states, a total of 1.9 million young adults, representing nearly 7 in 10 (66 percent) of the potentially Marketplace-eligible uninsured ages 18 to 34, may be able to pay $100 or less for coverage in 2014.
According to the report, an additional 1 million eligible uninsured single young adults may qualify for Medicaid in the states that have opted to expand the program in 2014. Today’s report also shows that if each of the 34 states expanded its Medicaid program, the proportion of young adults who could obtain low-cost coverage would be even greater. If each of the 34 states expanded its Medicaid program, 4.9 million uninsured single young adults would be eligible for Medicaid.
While some states are expanding their Medicaid programs in 2014, other states are not doing so. Under the health care law, states can receive 100 percent federal funding in 2014 to expand their Medicaid programs to cover people with incomes up to 133 percent of the federal poverty level. That’s about $15,800 a year for an individual, or about $32,500 for a family of four.
Friday, August 30, 2013
MEDICAL TESTING COMPANY WILL PAY $3.57 MILLION TO RESOLVE FALSE CLAIMS ACT ALLEGATIONS
FROM: U.S. JUSTICE DEPARTMENT
Tuesday, August 27, 2013
MRI Diagnostic Testing Company, Imagimed LLC, and Its Former Owners and Chief Radiologist to Pay $3.57 Million to Resolve False Claims Act Allegations
New York-based Imagimed LLC, the company’s former owners, William B. Wolf III and Dr. Timothy J. Greenan, and the company’s former chief radiologist, Dr. Steven Winter, will pay $3.57 million to resolve allegations that they submitted to federal healthcare programs false claims for magnetic resonance imaging (MRI) services, the Justice Department announced today. Imagimed owns and operates fifteen MRI facilities, located primarily in New York state, under the name “Open MRI.”
Allegedly, from July 1, 2001, through April 23, 2008, Imagimed, Greenan, Wolf and Winter submitted claims to Medicare, Medicaid and TRICARE for MRI scans performed with a contrast dye without the direct supervision of a qualified physician. Since a potential adverse side effect of contrast dye is anaphylactic shock, federal regulations require that a physician supervise the administration of contrast dye when it is used for an MRI. Also, allegedly, from July 1, 2005, to April 23, 2008, Imagimed, Greenan, Wolf and Winter submitted claims for services referred to Imagimed by physicians with whom Imagimed had improper financial relationships. In exchange for these referrals, Imagimed entered into sham on-call arrangements, provided pre-authorization services without charge and provided various gifts to certain referring physicians, in violation of the Stark Law and the Anti-Kickback Statute.
“The Department of Justice is committed to guarding against abuse of federal healthcare programs,” said Stuart F. Delery, Assistant Attorney General for the Civil Division. “We will help protect patients’ health by ensuring doctors who submit claims to federal healthcare programs follow proper safety precautions at all times.”
U.S. Attorney for the Northern District of New York, Richard S. Hartunian said: “This case is an example of our commitment to using all of the remedies available, including civil actions under the False Claims Act, to ensure patient safety and combat health care fraud. Stripping away the profit motive for circumventing physician supervision requirements has both a remedial and a deterrent effect. The settlement announced today advances our critical interest in both the integrity of our health care system and the safe delivery of medical services.”
The allegations resolved by the settlement were brought in a lawsuit filed under the False Claims Act’s whistleblower provisions, which permit private parties to sue for false claims on behalf of the government and to share in any recovery. The whistleblower in this case, Dr. Patrick Lynch, was a local radiologist and will receive $565,500.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $14.8 billion through False Claims Act cases, with more than $10.8 billion of that amount recovered in cases involving fraud against federal health care programs.
The investigation and settlement were the result of a coordinated effort among the U.S. Attorney’s Office for the Northern District of New York; the Justice Department’s Civil Division, Commercial Litigation Branch and the Department of Health and Human Services’ Office of Inspector General.
The case is United States of America ex rel. Lynch v. Imagimed LLC, et al. (N.D. N.Y.). The claims released by the settlement are allegations only, and there has been no determination of liability.
Tuesday, August 27, 2013
MRI Diagnostic Testing Company, Imagimed LLC, and Its Former Owners and Chief Radiologist to Pay $3.57 Million to Resolve False Claims Act Allegations
New York-based Imagimed LLC, the company’s former owners, William B. Wolf III and Dr. Timothy J. Greenan, and the company’s former chief radiologist, Dr. Steven Winter, will pay $3.57 million to resolve allegations that they submitted to federal healthcare programs false claims for magnetic resonance imaging (MRI) services, the Justice Department announced today. Imagimed owns and operates fifteen MRI facilities, located primarily in New York state, under the name “Open MRI.”
Allegedly, from July 1, 2001, through April 23, 2008, Imagimed, Greenan, Wolf and Winter submitted claims to Medicare, Medicaid and TRICARE for MRI scans performed with a contrast dye without the direct supervision of a qualified physician. Since a potential adverse side effect of contrast dye is anaphylactic shock, federal regulations require that a physician supervise the administration of contrast dye when it is used for an MRI. Also, allegedly, from July 1, 2005, to April 23, 2008, Imagimed, Greenan, Wolf and Winter submitted claims for services referred to Imagimed by physicians with whom Imagimed had improper financial relationships. In exchange for these referrals, Imagimed entered into sham on-call arrangements, provided pre-authorization services without charge and provided various gifts to certain referring physicians, in violation of the Stark Law and the Anti-Kickback Statute.
“The Department of Justice is committed to guarding against abuse of federal healthcare programs,” said Stuart F. Delery, Assistant Attorney General for the Civil Division. “We will help protect patients’ health by ensuring doctors who submit claims to federal healthcare programs follow proper safety precautions at all times.”
U.S. Attorney for the Northern District of New York, Richard S. Hartunian said: “This case is an example of our commitment to using all of the remedies available, including civil actions under the False Claims Act, to ensure patient safety and combat health care fraud. Stripping away the profit motive for circumventing physician supervision requirements has both a remedial and a deterrent effect. The settlement announced today advances our critical interest in both the integrity of our health care system and the safe delivery of medical services.”
The allegations resolved by the settlement were brought in a lawsuit filed under the False Claims Act’s whistleblower provisions, which permit private parties to sue for false claims on behalf of the government and to share in any recovery. The whistleblower in this case, Dr. Patrick Lynch, was a local radiologist and will receive $565,500.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $14.8 billion through False Claims Act cases, with more than $10.8 billion of that amount recovered in cases involving fraud against federal health care programs.
The investigation and settlement were the result of a coordinated effort among the U.S. Attorney’s Office for the Northern District of New York; the Justice Department’s Civil Division, Commercial Litigation Branch and the Department of Health and Human Services’ Office of Inspector General.
The case is United States of America ex rel. Lynch v. Imagimed LLC, et al. (N.D. N.Y.). The claims released by the settlement are allegations only, and there has been no determination of liability.
Monday, April 23, 2012
WALGREEN PAYS $7.9 MILLION TO RESOLVE FALSE PRESCRIPTION BILLING ACCUSATIONS
FROM: U.S. DEPARTMENT OF JUSTICE WEBSITE
Friday, April 20, 2012
Walgreens Pharmacy Chain Pays $7.9 Million to Resolve False Prescription Billing CaseAllegedly Offered Illegal Inducements to Government Health Care Programs Beneficiaries to Transfer Prescriptions to Walgreens
Walgreens, an Illinois-based corporation operating a national retail pharmacy chain, has paid the United States and participating states $7.9 million to resolve allegations that Walgreens violated the False Claims Act, the Justice Department announced today.
The settlement resolves allegations that Walgreens offered illegal inducements to beneficiaries of government health care programs, including Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits Program (FEHBP), in the form of gift cards, gift checks and other similar promotions that are prohibited by law, to transfer their prescriptions to Walgreens pharmacies. The government investigation alleged that Walgreens had offered government health beneficiaries $25 gift cards when they transferred a prescription from another pharmacy to Walgreens. The company’s advertisements that promoted gift cards and gift checks for transferred prescriptions typically acknowledged that the offer was not valid with Medicaid, Medicare or any other government program. Nevertheless, the government alleged that Walgreens employees frequently ignored the stated exemptions on the face of the coupons and handed gift cards to customers who were beneficiaries of government health programs, in violation of federal law.
“This case represents the government's strong commitment to pursuing improper practices in the retail pharmacy industry that have the effect of manipulating patient decisions,” said Stuart F. Delery, Acting Assistant Attorney General for the Civil Division of the Department of Justice.
The allegations were brought to the government by two whistleblowers, known as relators, in two separate whistleblower lawsuits filed under the qui tam, or whistleblower, provisions of the False Claims Act and state False Claims Act statutes. The relators, Cassie Bass, a pharmacy technician formerly employed by Walgreens, and Jack Chin, an independent pharmacist, will receive $1,277,172 from the United States for their role in filing the qui tam actions. The federal share of the settlement is $7,298,124.
“This case vindicates and protects the interests of consumers throughout the nation by ensuring that they remain free from undue influence by large retail chains when making decisions about which pharmacies to entrust their own individual health care,” said André Birotte Jr, U.S. Attorney for Central District of California.
“The law prohibits pharmacies from using their retail clout to lure patients whose prescriptions are subsidized by the government,” said Barbara L. McQuade, U.S. Attorney for the Eastern District of Michigan. “Continuity with a pharmacist is important to detect problems with dosages and drug interactions. Patients should make decisions based on legitimate health care needs, not on inducements like gift cards.”
“This settlement makes clear that corporations seeking increased profits over their patients' needs will pay a substantial price,” said Daniel R. Levinson, Inspector General for the Department of Health and Human Services. “Violating Federal health care laws, as Walgreens allegedly did by offering incentives for new business, cannot be tolerated.”
This resolution is part of the government's emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Secretary of the Department of Health and Human Services Kathleen Sebelius in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $6.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department's total recoveries in False Claims Act cases since January 2009 are over $9 billion.
This case was investigated jointly by the Commercial Litigation Branch of the Justice Department’s Civil Division, the U.S. Attorney’s Offices for the Central District of California and the Eastern District of Michigan, the National Association of Medicaid Fraud Control Units and the Department of Health and Human Services, Office of Inspector General.
The claims settled by today’s agreement are allegations only; there has been no determination of liability.
Friday, April 20, 2012
Walgreens Pharmacy Chain Pays $7.9 Million to Resolve False Prescription Billing CaseAllegedly Offered Illegal Inducements to Government Health Care Programs Beneficiaries to Transfer Prescriptions to Walgreens
Walgreens, an Illinois-based corporation operating a national retail pharmacy chain, has paid the United States and participating states $7.9 million to resolve allegations that Walgreens violated the False Claims Act, the Justice Department announced today.
The settlement resolves allegations that Walgreens offered illegal inducements to beneficiaries of government health care programs, including Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits Program (FEHBP), in the form of gift cards, gift checks and other similar promotions that are prohibited by law, to transfer their prescriptions to Walgreens pharmacies. The government investigation alleged that Walgreens had offered government health beneficiaries $25 gift cards when they transferred a prescription from another pharmacy to Walgreens. The company’s advertisements that promoted gift cards and gift checks for transferred prescriptions typically acknowledged that the offer was not valid with Medicaid, Medicare or any other government program. Nevertheless, the government alleged that Walgreens employees frequently ignored the stated exemptions on the face of the coupons and handed gift cards to customers who were beneficiaries of government health programs, in violation of federal law.
“This case represents the government's strong commitment to pursuing improper practices in the retail pharmacy industry that have the effect of manipulating patient decisions,” said Stuart F. Delery, Acting Assistant Attorney General for the Civil Division of the Department of Justice.
The allegations were brought to the government by two whistleblowers, known as relators, in two separate whistleblower lawsuits filed under the qui tam, or whistleblower, provisions of the False Claims Act and state False Claims Act statutes. The relators, Cassie Bass, a pharmacy technician formerly employed by Walgreens, and Jack Chin, an independent pharmacist, will receive $1,277,172 from the United States for their role in filing the qui tam actions. The federal share of the settlement is $7,298,124.
“This case vindicates and protects the interests of consumers throughout the nation by ensuring that they remain free from undue influence by large retail chains when making decisions about which pharmacies to entrust their own individual health care,” said André Birotte Jr, U.S. Attorney for Central District of California.
“The law prohibits pharmacies from using their retail clout to lure patients whose prescriptions are subsidized by the government,” said Barbara L. McQuade, U.S. Attorney for the Eastern District of Michigan. “Continuity with a pharmacist is important to detect problems with dosages and drug interactions. Patients should make decisions based on legitimate health care needs, not on inducements like gift cards.”
“This settlement makes clear that corporations seeking increased profits over their patients' needs will pay a substantial price,” said Daniel R. Levinson, Inspector General for the Department of Health and Human Services. “Violating Federal health care laws, as Walgreens allegedly did by offering incentives for new business, cannot be tolerated.”
This resolution is part of the government's emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Secretary of the Department of Health and Human Services Kathleen Sebelius in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $6.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department's total recoveries in False Claims Act cases since January 2009 are over $9 billion.
This case was investigated jointly by the Commercial Litigation Branch of the Justice Department’s Civil Division, the U.S. Attorney’s Offices for the Central District of California and the Eastern District of Michigan, the National Association of Medicaid Fraud Control Units and the Department of Health and Human Services, Office of Inspector General.
The claims settled by today’s agreement are allegations only; there has been no determination of liability.
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