WHITE HOUSE ANNOUNCES EXECUTIVE ACTIONS TO IMPROVE CARE FOR MEDICARE BENEFICIARIES

FROM:  THE WHITE HOUSE 

October 06, 2014

FACT SHEET: Administration Announces New Executive Actions to Improve Quality of Care for Medicare Beneficiaries

Today, the Administration announced new executive actions and the President signed into law legislation that will improve the quality of care for nursing home and home health patients. The President signed the Improving Medicare Post Acute Care Transformation Act of 2014 (IMPACT Act), bipartisan legislation that puts in place new and streamlined quality measures for nursing homes, home health agencies, and other post-acute care providers participating in Medicare. The Administration also took additional steps to improve care for nursing home and home health patients through new executive actions that will:

Expand and strengthen Medicare’s widely-used Five Star Quality Rating System for Nursing Homes, also known as Nursing Home Compare.
Improve quality home health care received by Medicare beneficiaries through a proposed rule that strengthens patient rights, improves communication, and focuses on patient well-being.
Actions to Improve Medicare’s Five Star Quality Rating System for Nursing Homes

Today, the Administration announced plans to expand and strengthen Medicare’s widely-used Five Star Quality Rating System for Nursing Homes, also known as Nursing Home Compare.  The rating system is a consumer service that offers useful information to the public about the quality of care in the 15,800 nursing homes that participate in Medicare or Medicaid.  Users may sort through nursing homes in their area through an online tool at CMS’ Nursing Home Compare website.

The Five Star Quality Rating System offers the most comprehensive overview of nursing home quality in the U.S., in an easy to understand format, based on data from onsite inspections conducted by trained, objective surveyors from state public health departments and CMS; Quality Measures submitted by the nursing homes is used to calculate certain quality measures, such as the prevalence of pressure ulcers, use of restraints, and the extent of injurious falls; and information about the staffing levels in nursing homes.

While the onsite inspections form the core of the rating system, CMS has been concerned that the quality measures and information about staffing levels rely on self-reported data from nursing homes that have been difficult to verify.

Beginning in January 2015 CMS will initiate the following steps to improve the reliability and utility of data displayed on Nursing Home Compare as well as to help nursing homes improve:

Nationwide Focused Survey Inspections:  In FY 2014 CMS piloted special surveys of nursing homes that focused on verifying performance on resident assessments and the data set that is used in the quality measures.  Effective January 2015, CMS and states will implement these focused survey inspections nationwide for a sample of nursing homes nationwide.  Expansion of these inspections will enable better verification of both the staffing and quality measure information that is part of the Five-Star Quality Rating System.

Payroll-Based Staffing Reporting: Using new funding provided by the IMPACT Act of 2014, signed by the President today, CMS will implement a system of quarterly electronic reporting that is auditable back to payrolls to verify staffing information.  This new system will increase accuracy, improve the timeliness of the data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing.  This data will not only allow for better information available to the public, but may equip nursing homes with better data by which to improve staffing and quality of care.  CMS expects that pilot testing will occur in fiscal year (FY) 2015, with nationwide reporting by all nursing homes by the end of FY2016.

Improved Scoring Methodology: CMS will revise the scoring methodology by which we calculate each facility’s Five Star rating. The revised scoring methods will place more emphasis on data that is verified by independent sources rather than data that is self-reported by nursing homes.
Timely and Complete Inspection Data: CMS will also strengthen requirements to ensure that states complete inspections of nursing homes in a timely and accurate manner, and maintain a user-friendly website for public viewing.
Additional Quality Measures: CMS will increase both the number and type of quality measures used in Nursing Home Compare.  The first additional measure starting January 2015 in the ratings system will be the extent to which anti-psychotic medications are in use. More measures will be added later, including data on re-hospitalization and rates of returning beneficiaries to home that use Medicare claims as the source of information.
Actions to Improve Quality Home Health Care Received by Medicare Beneficiaries

In conjunction with today’s efforts to improve the quality of care received by Medicare beneficiaries in nursing homes, the Centers for Medicare & Medicaid Services today issued a proposed rule that strengthens patient rights, improves communication, and focuses on patient well-being. These rules are designed to improve the quality of home health services for Medicare beneficiaries.

These updates to home health agency conditions of participation (CoPs) make substantial revisions to the existing CoPs.  They focus on the care needs of patients and will clarify the operational and quality expectations for the approximately 12,500 home health agencies participating in Medicare. There are more than five million people with Medicare and Medicaid benefits who receive home health care services each year.

The proposed regulation, will include these proposed updates:

A clear explanation of patient rights, including a requirement to communicate with patients in a language and manner that they understand, and a requirement that home health agencies must take measures to assure and protect those rights.
An expanded comprehensive patient assessment requirement that focuses on all aspects of patient well-being.

An integrated communication system, increasingly enabled by health information technology, that ensures that patient needs are identified and addressed, care is coordinated among all disciplines, and that there is active, timely, needs-based communication between the home health agency and the physician.
A data-driven, agency-wide quality assessment and performance improvement program that continually evaluates and improves agency care for patients.
An expanded patient care coordination requirement that makes a licensed clinician responsible for all patient care services, such as coordinating referrals and assuring that plans of care meet each patient’s needs at all times.
Comments and feedback are requested to inform final rulemaking in 2015.

IMPACT Act

The President signed the Improving Medicare Post-Acute Care Transformation Act of 2014, bipartisan legislation that puts in place new and streamlined quality measures for nursing homes, home health agencies, and other post-acute care providers participating in Medicare.

The Act will facilitate patients comparing outcomes across different care settings, supporting better choices and better outcomes for patients. In addition, the IMPACT Act funds a key improvement to nursing home oversight, the collection of staffing data. Nursing and other staffing levels are closely correlated with quality in nursing homes and current data collection efforts have produced data of uneven reliability. The IMPACT Act also institutes more routine surveys of hospice providers, ensuring program standards are met for the benefit and safety of patients.

HHS TOUTS NEW TRANSPARENCY ON MEDICAL SERVICES AND HOW PHYSICIANS ARE PAID

FROM:  DEPARTMENT OF HEALTH AND HUMAN SERVICES 

FOR IMMEDIATE RELEASE
April 9, 2014

Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid
Today, as part of the Obama administration’s work to make our health care system more transparent, affordable, and accountable, Health and Human Services (HHS) Secretary Kathleen Sebelius announced the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.

“Currently, consumers have limited information about how physicians and other health care professionals practice medicine,” said Secretary Sebelius “This data will help fill that gap by offering insight into the Medicare portion of a physician’s practice. The data released today afford researchers, policymakers and the public a new window into health care spending and physician practice patterns.”

The new data set has information for over 880,000 distinct health care providers who collectively received $77 billion in Medicare payments in 2012, under the Medicare Part B Fee-For-Service program. With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.

The information also allows comparisons by physician, specialty, location, the types of medical service and procedures delivered, Medicare payment, and submitted charges. Physicians and other health care professionals determine what they will charge for services and procedures provided to patients and these “charges” are the amount the physician or health care professional generally bills for the service or procedure.

"Data transparency is a key aspect of transformation of the health care delivery system,” said CMS Administrator Marilyn Tavenner. “While there’s more work ahead, this data release will help beneficiaries and consumers better understand how care is delivered through the Medicare program.”

Last May, CMS released hospital charge data allowing consumers to compare what hospitals charge for common inpatient and outpatient services across the country.

MEDICAL CLINIC OWNER PLEADS GUILTY FOR ROLES IN HEALTH CARE FRAUDS TOTALING OVER $20 MILLION

FROM:  JUSTICE DEPARTMENT 
Tuesday, January 7, 2014
Medical Clinic Owner Pleads Guilty in Miami for Role in Multiple Health Care Fraud Schemes Totaling Over $20 Million

The owner and operator of a Miami medical clinic pleaded guilty today in connection with multiple health care fraud schemes involving the defunct clinic Merfi Corp.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida, Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office, and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office made the announcement.

Isabel Medina, 49, of Miami, pleaded guilty before U.S. District Judge Ursula Ungaro of the Southern District of Florida to conspiracy to commit health care fraud, which carries a maximum penalty of 10 years in prison.   Sentencing has been scheduled for March 14, 2014.

According to court documents, Medina was an owner and operator of Merfi, a Miami medical clinic which employed physicians, physician assistants and other medical professionals who were authorized by law to dispense prescriptions for home health care services.   Through Merfi, Medina and her co-conspirators provided fraudulent home health and therapy prescriptions and other medical documentation to the owners and operators of Flores Home Health Care Inc. and other home health care agencies, as well as to patient recruiters, in return for kickbacks and bribes.

Flores Home Health and these other home health care agencies purported to provide home health and therapy services to Medicare beneficiaries, but were in fact operated for the purpose of billing the Medicare program for, among other things, expensive physical therapy and home health care services that were not medically necessary and/or not provided.

Medina has acknowledged that her involvement in fraudulent schemes at multiple home health care companies, including Flores Home Health, resulted in losses to the Medicare Program exceeding $20 million.

The case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division's Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.   This case is being prosecuted by Trial Attorney A. Brendan Stewart of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

FORMER MENTAL-HEALTH THERAPIST SENTENCED TO 120 MONTHS IN PRISON FOR ROLE IN MEDICARE FRAUD

FROM:  U.S. JUSTICE DEPARTMENT 
Wednesday, November 6, 2013
Former Mental-Health Clinic Therapist Sentenced for Role in $55 Million Medicare Fraud Scheme

A former therapist for Biscayne Milieu, a Miami-based mental-health clinic, was sentenced today to serve 120 months in prison for his participation in a $55 million Medicare fraud scheme.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida, Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services’ Office of Inspector General (HHS-OIG) Miami office made the announcement.

Jose Rojo, 39, of Miami, was sentenced by U.S. District Judge Marcia G. Cooke in the Southern District of Florida.  Rojo was convicted on Aug. 7, 2013, of one count of conspiring to commit health care fraud following a one-month jury trial.  In addition to the prison term, Rojo was ordered to pay more than $11 million in restitution, jointly and severally with his co-defendants, and to serve three years of supervised release.

According to the evidence at trial, Rojo and his co-conspirators caused the submission of more than $55 million dollars in fraudulent claims to Medicare through Biscayne Milieu, which purportedly operated a partial hospitalization program (PHP) – a form of intensive treatment for severe mental illness.  Instead of providing PHP services, the defendants devised a scheme in which they paid patient recruiters to refer ineligible Medicare beneficiaries to Biscayne Milieu for services that were never provided.  Many of the patients admitted to Biscayne Milieu were not eligible for PHP because they were chronic substance abusers, suffered from severe dementia and would not benefit from group therapy, or had no mental health diagnosis but were seeking exemptions for their U.S. citizenship applications.

The evidence at trial further showed that, as a therapist at Biscayne Milieu, Rojo conducted sham therapy sessions for patients he knew were ineligible for PHP treatment.  Often Rojo showed up late for these sessions or not at all, but Medicare was still billed as if a full session took place.  Rojo created fraudulent documents to help cover-up Biscayne Milieu’s massive fraud, including bogus treatment plans and phony group therapy notes that were copied from one document to the other.  Deliberately inaccurate group therapy notes for different patients on different days – often years apart – were in many respects identical, including having the same descriptions of patients’ statements in group sessions and even the same misspelled words.  Further, Rojo provided other therapists at the clinic with fake group therapy notes for a fee.  Biscayne Milieu billed Medicare for tens of millions of dollars in PHP treatments for these patients.

Various owners, doctors, managers, therapists, patient brokers and other employees of Biscayne Milieu have also been charged with health care fraud, kickback violations, money laundering and other offenses in two indictments unsealed in September 2011 and May 2012.  Biscayne Milieu, its owners, and more than 25 of the individual defendants charged in these cases have pleaded guilty or have been convicted at trial.  Antonio and Jorge Macli and Sandra Huarte – the owners and operators of Biscayne Milieu – were each convicted at trial and were sentenced in April 2013 to 30 years, 25 years and 22 years in prison, respectively.

This case was investigated by the FBI with the assistance of HHS-OIG and was brought by the the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida. The case is being prosecuted by Assistant U.S. Attorneys Marlene Rodriguez and James V. Hayes of the Southern District of Florida; Hayes was formerly a trial attorney of the Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $5 billion.  In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.