Billings Used Dead Doctors' Names

By Christopher Lee, Washington Post Staff Writer
washingtonpost.com | Wednesday, July 9, 2008

Medicare has paid as much as $92 million since 2000 to medical suppliers who billed the government for wheelchairs and other home equipment purportedly prescribed by physicians who, according to records, were dead at the time, congressional investigators said yesterday.

The Centers for Medicare and Medicaid Services (CMS) honored about 500,000 such claims despite pledging six years ago to correct the problem, which was identified by the Health and Human Services Department's inspector general in 2001.

In more than half the cases studied, the doctor listed as having ordered the equipment had died more than five years earlier, said a report by the Senate Homeland Security and Governmental Affairs Committee's permanent subcommittee on investigations.

"We discovered that some medical equipment suppliers have scammed the Medicare system -- and the American taxpayers -- out of massive amounts of money," Sen. Norm Coleman (Minn.), the panel's top Republican, said in a statement. "Using the ID numbers of dead doctors, these scam artists have treated Medicare like an ATM machine, drawing money out of the government's account with little fear of getting caught."

The report is part of the committee's ongoing investigations into waste, fraud and abuse in the fast-growing federal health program, which serves more than 43 million elderly and disabled Americans. Medicare pays annually more than $400 billion in benefits and is a fixture on the Government Accountability Office's "high-risk" list of troubled programs.

Last year, the government established a Medicare Fraud Strike Force to crack down on a problem that officials estimate costs taxpayers tens of billions of dollars annually. The program's durable medical equipment component, in particular, has been a frequent target of companies seeking to bilk the government. The subcommittee has scheduled a hearing on the problem today. When the system works properly, a physician writes a prescription for home medical equipment for a Medicare beneficiary. He takes the order to a supplier, who sells or rents the equipment to him. The supplier, in turn, submits a claim for payment to a Medicare contractor for processing. The claim includes a number issued by Medicare that identifies the prescribing physician.

Senate investigators obtained from the American Medical Association a computer file of physicians who had died between 1992 and 2002. They selected 1,500 at random and asked Medicare officials to turn over medical-equipment claims filed with those doctors' Medicare ID numbers between 2000 and 2007.

During that time, the review said, ID numbers for 734 deceased doctors were used to file 21,458 claims that totaled $3.4 million. Investigators counted the claims only if the equipment was bought more than a year after the doctor's death.

Extrapolating from the sample, investigators estimate that 384,730 to 572,238 such fraudulent claims were submitted during that period, and Medicare paid an estimated $60 million to $92 million. There are still active ID numbers in Medicare's system for as many as 2,895 dead physicians, investigators said.

They examined separate data for Florida, home to many retirees and a perennial leader in Medicare fraud. They found that more than a quarter of deceased Medicare doctors there still have active ID numbers in Medicare's system.

The ID for one doctor, who died in 1999, appeared on 83 claims submitted by Professional Gluco Services Inc., a Miami company, between November 2005 and September 2006. A federal grand jury indicted two of the company's owners last year on charges of defrauding the government of $1.3 million for equipment that had never been ordered or delivered. Both men pleaded guilty.

Medicare officials had promised to do a better job screening claims after the 2001 inspector general's report found that the agency had paid $91 million for medical supply claims with invalid or inactive physician ID numbers in 1999.

Medicare officials said several new steps should help, including a plan to match monthly Social Security Administration data about U.S. deaths against a revamped Medicare provider-identification system. They also pointed to new accreditation requirements for suppliers under a new program, opposed by the industry, that sets some equipment prices through competitive bidding.

"Fraud and abuse in the context of Medicare-covered durable medical equipment has been a focal point of ours in recent years," said CMS spokesman Jeff Nelligan. "Before this program, anyone could become a supplier, but now they must be fully accredited based on strict financial and quality standards."

Muscling in on Medicare

Legislative fight in Washington puts patients in midst of doc-insurer struggle

July 8, 2008 | Newsday.com

A Medicare tweak on the table in Washington is pitting doctors against insurers - with patients in the middle. Doctors are facing a steep cut in Medicare payments, and many say that if that happens, they'll reduce or end their participation in the program. And that will make it harder for elderly patients to get care.

The alternative is to trim what Washington pays private, Medicare Advantage plans. Insurers, some of whom underwrite those plans, are airing television commercials warning that will mean patients losing coverage or paying more.

For patients, this all sounds like heads you lose, tails you lose. But things aren't that bleak. Not if Medicare Advantage plans take the hit, as they should.

The problem is that doctor reimbursements will be slashed 10.6 percent unless Congress acts to stop it. A cut that deep is unrealistic. The House voted June 24 to increase payments to physicians by 1.1 percent. But the bill is stalled in the Senate and, should it pass, President George W. Bush has threatened a veto. The sticking point is cost.

The bill would take the money from those private plans - which is where it should come from. Medicare Advantage plans were pushed by private marketers who said they would save taxpayer dollars. But Washington pays the plans 13 percent more per beneficiary than it would cost to cover that same person under government-run Medicare.

Pitting private plans against traditional Medicare is a sound idea. Competition should make each better. But a fair contest requires a level playing field, and right now it isn't. Not with private plans being paid more per patient.

The pending legislation wouldn't end that disparity. But it would reduce it and free up money to pay doctors. That would be a win for most Medicare patients and taxpayers.

Healthcare groups use ads to lobby lawmakers on Medicare bill

July 03 2008 | McKnight's Long Term Care News

Congress may be on break this week, but two industry groups launched ads spurring the Senate to take action on a Medicare bill that affects nursing home residents and other older adults when it returns from the Fourth of July recess.

The American Medical Association unveiled an advertising campaign to encourage passing the bill, H.R. 6331. Targeted towards opponents of the legislation, the ads say the issue boils down to a choice: insurance company profits, or seniors and disabled vets who will lose their access to healthcare. Meanwhile, insurance lobbyists are working on their own anti-H.R. 6331 advertising blitz. They argue that the cuts to Medicare Advantage plans that would fund the bill would limit choices, reduce benefits and pass on higher costs to seniors.

This week, two harmful actions went into effect: the expiration of the exceptions process for Part B outpatient therapy caps, and a freeze on Medicare physician payments. Therapy caps, which affect nursing home residents, impose a $1,810 limit on physical therapy and speech therapy combined and $1,810 on occupational therapy for nursing home residents. Residents in Medicare-certified beds at a skilled nursing facility will not have therapeutic services covered past $1,810, according to a note from the Centers for Medicare & Medicaid Services. Others who exceed the cap, however, may obtain medically necessary therapy services at a hospital.

EDS unit to process Medicare claims in four states

07/02/08 -- 01:37 PM
By David Hubler | Washington Technology

NHIC Corp. will process Medicare payment claims from health care providers in four Northwestern states under a $148 million contract from the Centers for Medicare and Medicaid Services.

The contract, which has a one-year base period and four one-year options, will serve about 54,000 physicians and health care practitioners and 233 hospitals in Alaska, Idaho, Oregon and Washington state.

NHIC, a subsidiary of EDS Corp., will provide a variety of administrative functions for hospitals, skilled nursing facilities and physicians in those states and will be the providers’ first point of contact for processing and payment of Medicare Parts A and B fee-for-service claims.

The company will also handle appeals, audits and reimbursements, provider enrollment, educational outreach, print and mail services, financial and accounting services, contact-center support, electronic data exchange, mailroom operations, and medical and utilization reviews.

The contract will help CMS meet the requirements of the Medicare Modernization Act of 2003, which requires the agency to transition Medicare fee-for-service claims from fiscal intermediaries and carriers to Medicare administrative contractors, NHIC said in a statement.

NHIC is one of the largest Medicare Part B contractors in the country, serving more than 150,000 health care providers in California, Maine, Massachusetts, New Hampshire and Vermont.

EDS, of Plano, Texas, ranks No. 10 on Washington Technology’s 2008 Top 100 list of the largest federal government prime contractors.

Medicare Payment Fiasco Causes Delay in Claims Processing

Action Should Not Mean Delayed Payments

By James Arvantes | AAFP News Now
7/1/2008

The Bush administration has announced it will delay the processing, but not necessarily the payment, of Medicare claims to give Congress more time to pass a bill blocking a 10.6 percent reduction in the Medicare payment rate. However, the administration's action should not result in delayed Medicare payments to physicians, said Kent Moore, the AAFP's manager of health financing and delivery systems.

CMS is required by law to hold Medicare claims it receives for 14 days before issuing payment on the claims. In normal circumstances, the agency starts to process claims within a few days of receiving them, paying them by the end of the 14-day time frame, Moore said. CMS now plans to hold Medicare claims for 10 business days before processing them to give Congress more time to pass Medicare payment legislation that is expected to negate a 10.6 percent payment cut effective July 1.

"CMS will use that 14-day window they have statutorily and refrain from processing the claim," Moore said. "Instead of processing (a claim) at the front end of that 14 days, they will process it 10 days later on the hope that Congress will act within the first days of July," said Moore. "Physicians should not see a delay in payment," he added.

In late June, the House overwhelming passed an 18-month Medicare physician payment bill that would have prevented the 10.6 percent reduction scheduled for the remainder of this year, along with a 5.4 percent cut scheduled for 2009. But the Senate failed to pass the legislation, allowing the 10.6 percent cut to take effect on July 1. Congress adjourned for a weeklong July 4 recess on June 27 and will return on July 7. Senate Majority Leader Harry Reid, D-Nev., in a prepared statement, said the Senate would address the Medicare legislation shortly after returning from the July 4 break.

Many physicians, meanwhile, are upset and angry, said Moore, thinking CMS will withhold Medicare payments, a perception that he characterizes as a misunderstanding.

"CMS is simply saying that they are going to take advantage of the 14-day payment floor they already have by law," Moore said. "They still intend to pay claims in a timely manner."

Although physicians will experience a reduction in their Medicare payment levels if Congress and the Bush administration cannot agree on a Medicare payment bill by mid-July, there is an expectation that they will agree on a payment bill by then and will make the legislation retroactive to July 1.

CMS has said that physicians should submit their Medicare claims for services on or after July 1 using the pre-July 1 scheduled amount. Claims submitted after June 30 that reflect the 10.6 percent reduction will be paid based on that amount, and "will likely require providers to resubmit a revised claim," said CMS in a June 30 press release.

Submitting claims with pre-July 1 amounts "will facilitate reprocessing of the claims by CMS, if needed, and will ensure that physicians are able to collect the full pre-July 1 allowed amount, when or if the cut is retroactively negated," said Moore.

However, noted Moore, "physician practices may only collect copayments and deductibles from Medicare beneficiaries based on the reduced (Medicare) rate, even if they are charging the pre-July 1 rate to Medicare."

Physician practices wishing to avoid confusion may choose to hold their Medicare claims in-house until it becomes clear that new legislation will be enacted or until cash flow becomes a problem, said Moore. "This will reduce the need for (physicians) to reconcile two payments -- the initial claim and the reprocessed claim -- and it will simplify physician billings of beneficiary co-insurance and payment calculations for payers that are secondary to Medicare," said Moore.

Medical Fraud a Growing Problem

Medicare Pays Most Claims Without Review

By Carrie Johnson
Washington Post Staff Writer
Friday, June 13, 2008; A01

MIAMI -- All it took to bilk the federal government out of $105 million was a laptop computer.

From her Mediterranean-style townhouse, a high school dropout named Rita Campos Ramirez orchestrated what prosecutors call the largest health-care fraud by one person. Over nearly four years, she electronically submitted more than 140,000 Medicare claims for unnecessary equipment and services. She used the proceeds to finance big-ticket purchases, including two condominiums and a Mercedes-Benz.

Health-care experts say the simplicity of Campos Ramirez's scheme underscores the scope of the growing fraud problem and the need to devote more resources to theft prevention. Law enforcement authorities estimate that health-care fraud costs taxpayers more than $60 billion each year.

A critical aspect of the problem is that Medicare, the health program for the elderly and the disabled, automatically pays the vast majority of the bills it receives from companies that possess federally issued supplier numbers. Computer and audit systems now in place to detect problems generally focus on overbilling and unorthodox medical treatment rather than fraud, scholars say.

"You should be able to spot emerging problems quickly and address them before they do much harm," said Malcolm Sparrow, a Harvard professor and author of "License to Steal," a book about health-care fraud that advocates for greater federal vigilance. "It's a miserable pattern, a cycle of neglect followed by a painful and dramatic intervention."

Fallout from the Campos Ramirez case continues. After pleading guilty to filing false claims, she has helped authorities win indictments against more than half a dozen doctors and patients who allegedly accepted kickbacks for pretending to receive costly HIV drug therapy. With cooperation from Campos Ramirez, FBI agents this week arrested three Miami-area men who, the government alleges, financed sham clinics that billed the government more than $100 million.

Daniel R. Levinson, the inspector general of the Department of Health and Human Services, has warned repeatedly that the Medicare program is "highly vulnerable" to fraud, particularly in South Florida, where schemes center on expensive, infusion-based HIV medications and on equipment such as wheelchairs, walkers, canes and hospital beds.

Officials from the Centers for Medicare and Medicaid Services (CMS), which oversees federally funded health programs, say they have stepped up their efforts to combat fraud over the past year by working closely with investigators, removing the requisite billing numbers of nearly 900 companies and imposing new standards in high-fraud areas that would prevent people convicted of felonies from ever receiving a Medicare number.

"There's always more fraud than we have resources to combat," said Kimberly L. Brandt, director of program integrity at CMS. "We have done a much better job of realigning our resources to attack this problem."

Investigators and prosecutors trained their focus on Miami after noticing two troubling patterns:

· HHS investigators discovered that nearly half of 1,581 medical equipment companies they visited in the Miami area did not comply with basic Medicare requirements to be open during scheduled hours and to have a telephone number. The inspector general and the Government Accountability Office have flagged weak oversight of these kinds of suppliers for a dozen years, according to congressional testimony.

· The South Florida region bills Medicare more than $2 billion each year for injectable HIV medications. That figure is 22 times as high as the amount of similar claims in the rest of the country, and is far out of line with demographic data in a population of 2 million people in Miami-Dade County, HHS statistics show.

Justice Department officials moved to freeze money in suspicious bank accounts controlled by medical equipment company owners and they created a Washington-based strike force to handle the issue. The strike force, in concert with a small group of U.S. attorney's offices, has in the past year opened nearly 900 criminal investigations and convicted 560 defendants in health-care fraud offenses throughout the country.

Authorities say the strategy is working. They point to a $1.75 billion drop in Medicare claims in Miami since the operation began a year ago. But even government officials hope for a more comprehensive solution.

Christopher Dennis, the special agent in charge of the HHS inspector general's office in Miami, said fraudulent medical equipment companies appear to have shifted gears since the strike force arrived. After a crackdown in South Florida, at least some corporate owners moved to the north, he said. Investigators dubbed one initiative "Operation Whack-a-Mole," after the carnival game in which a creature pops up in different places after being hit with a hammer.

"The sheer number of zeroes following the dollar sign is irresistible to crooks and con men," Attorney General Michael B. Mukasey said last month during a Miami visit. "For every crooked company we bust, there is another one to replace it before the ink on the indictment is dry. . . . The money and the temptation are simply too big."

The strike force recently established a base in Los Angeles, another area rife with fraud. Prosecutors announced criminal charges last month against two medical equipment company owners who are accused of falsely billing Medicare more than $2 million. Plans call for a similar rollout this fall in Houston, another potential fraud hot spot.

"You can see how these frauds spread through communities," said Kirk Ogrosky, who is deputy chief in the Justice Department's fraud section and helps lead the strike force. "Family members and friends just get sucked into it. It's really rags to riches on the backs of the American taxpayer."

Officials who oversee the Medicare program say they are vigilant despite time pressure and limited resources. Employees review fewer than 5 percent of the nearly 1 billion claims filed each year. The vast majority of claims shuttle through computer systems that are tweaked when authorities notice fraud patterns. This year, CMS is working to finalize a rule that would prevent convicted felons from obtaining Medicare billing numbers. At present, that regulation applies only in a few high-fraud regions.

"It's a big volume," Brandt said. "No matter how hard we try to get people trained, there's always going to be a margin of error."

Sentenced to 10 years, Campos Ramirez, 60, may yet reduce her prison term by helping authorities unwind "the large web of medical clinics, doctors, nurses, money laundering companies and HIV clinic financiers who participated in this massive fraud," prosecutors wrote earlier this year in court papers. Her lawyer did not return calls seeking comment.

By many accounts, Campos Ramirez was unusually successful. Prosecutors say that corrupt medical clinic owners anticipate that Medicare will cover a quarter of their phony claims. But Campos Ramirez persuaded authorities to cover 60 percent of all the bills she submitted on behalf of 75 HIV clinics in South Florida, according to court filings.

As the owner of R and I Medical Billing, Campos Ramirez advised clinic owners how to justify the costly HIV treatments and manipulated Medicare claims to make sham clinics appear to be legitimate health-care facilities, prosecutors said. She personally collected more than $5 million with which she bought property and luxury items. Over the past year, however, Campos Ramirez has met repeatedly with law enforcement agents to unravel the scheme, which ran from 2002 to 2006.

At the time of her sentencing in March, Campos Ramirez had amassed a net worth of $1.5 million, including one of the condominiums where her son, an employee of her billing company, had lived.

A look at the presidential candidates' health care proposals

Sunday, June 8, 2008
By Linda Redeffer
TBY | SOUTHEAST MISSOURIAN

As candidates campaign for the nation's highest office, they make promises about reforming health care. Actually delivering on those promises can be another matter entirely.

A visit to the Cape Girardeau Senior Center revealed that most retired people there that day had Medicare and a supplement and were, for the most part, satisfied with them. Some have found they unexpectedly had to dip into their savings to pay for health care costs.

Brenda Hargrave, part-time administrative assistant at the center, has looked at the health care proposals from candidates John McCain, Barack Obama and Hillary Clinton. She said that while she has not yet decided whom she will vote for, she believes Obama has the best proposal.

But any real kind of health care reform will not come from anyone running for office, Hargrave said.

"While [Obama] addresses concerns, there are things going on that if they would enforce what they already have in place, the government would be out a lot less money now," she said.

Hargrave said she has 30 years' experience in medical billing, collecting and management. She has seen first hand where reform needs to take place, she said.

Health care reform, she said, should start with the "usual and customary rates," or UCR, established by Medicare and Medicaid. Medicare/Medicaid providers say they will pay 80 percent of an insured person's medical costs, but in fact pay an amount based on what they consider "usual and customary," often less than what a doctor or hospital charges. Physicians and hospitals write off the difference and recoup it from patients with private insurance or uninsured patients who are expected to pay full price for procedures, often in advance of being treated, Hargrave said.

"If doctors participate in Medicare they're not allowed to charge more than a certain amount. Some doctors refuse to take any new Medicare patients because they know they can't get any more money," she said. "They leave room on their schedule for other patients with private health insurance because they know they will get more money."

"Everybody needs the same UCR, whether private, Medicare, Medicaid or whatever. No insurance should be charged more than the UCR; UCR should be established across the board."

Better oversight on Medicare/Medicaid billing could save hundreds of thousands of dollars, Hargrave contends.

"I have personal knowledge of one Medicare patient who had a problem with Medicare," she said. "I kept billing, trying to get them to pay. When they did pay, they paid 20 times for the same office procedure. The money went in that patient's account as a credit. I was told not to return credits until somebody found them."

When she made one company aware of double billing for a one-time procedure, she said "nothing was done about it. That's why insurance costs are out of line."

Hargrave said more people should monitor their doctors' office billing procedures and codes and compare what is being charged with the work actually delivered.

"If we could get that done, then health insurance will be within reason and the government will have a lot more money," she said.

Hargrave said she would like to see part-time employees have access to the same insurance as full-time employees. For a semiretired person not yet on Medicare, the cost of health insurance leaves little money for other living expenses. Yet some companies, she said, will hire several part-time people to avoid the cost of providing insurance for a full-time employee.

Monitoring costs and codes would be frustrating and time-consuming for most people. Karen Riley of Cape Girardeau said she and her husband, Dean, are both on Medicare and have a supplemental policy. Both Medicare and the supplement pay for mammograms.

"I called Southeast Missouri Hospital to see if it is in the network," she said. "They said yes. But the doctor who read it was out of network. Since Jan. 15, both insurance companies are arguing over who is going to pay the bill. It has still not been paid."

Riley said she and her husband pay high premiums for their supplemental insurance, partly because she has a pre-existing condition. They dipped into their savings to pay for medical costs and insurance premiums after her husband, who worked at Southeast Missouri State University in the facilities management department, required knee surgery and retired early as a result. While he was working, the university covered the cost of his health care premiums. Until both qualified for Medicare, their monthly costs after he retired meant "we were paying money we could have spent on something else," she said. "It's got to stop somewhere. We can't keep on paying and paying and paying. You can save for retirement, but when you're saving you don't anticipate your medical costs going up and up and up."

Nor did she anticipate that just changing doctors would result in the second doctor asking for lab tests that had already been done not long before that, "so they can get more money."

Riley said she believes Clinton has the best health care proposal.

"She is saying lower premiums and give better quality insurance," Riley said.

Harry Floyd, a retired business owner, said he was considering dropping his supplemental policy because he could pay out of pocket for health expenses for less than his $145-a-month premium. His table companions urged him to keep it, saying they envied him that low premium and warning him that his medical expenses could go up drastically with one illness. Floyd is one of the few not adversely affected by health care costs. He said he supports Clinton because "she has the background. Her husband was president, so she knows a little bit about the ins and outs.

"I figure most wives know what their husbands do and she has a little insight."

Hargrave said that at whatever level health care reform comes, it has less to do with whomever is elected than with the person at the bureaucratic level chosen to implement and manage it. She said she told that to U.S. Rep. Kenny Hulshof when he campaigned at the senior center in his bid for governor.

"I told [him] if anybody is going to reform the health system, it needs to be somebody who knows what he is doing and knows what the program is all about, not somebody who donated money to a campaign," she said.

This article was printed in the June edition of TBY (The Best Years), a special publication of the Southeast Missourian.

Which health insurance system do you favor?

Jun 03, 2008, By William McKenzie
Opinion Blog | The Dallas Morning News

There are essentially three ways to knock down the number of uninsured Americans:

1. The government can be responsible for insuring Americans between ages 25-65. Think a system like Medicare for all Americans.

2. Businesses should be responsible for covering all their workers.

3. Individuals should be responsible for their own insurance.

Which option do you favor? Why?

Reluctantly and slowly, I've come around to the last option. Here's why:

1. Employer-based insurance has been the model we've used for the last several decades, but it's hard to argue that the employer model is sustainable for the next few decades. It's revealing that the percentage of Americans covered by their employers has actually been declining, not increasing. With health costs so great, and businesses strapped to meet them and other expenses, it's hard for me to see how that trend will reverse itself.

If it could, I probably would favor continuing using it as the model. But I just don't see it. And I sure don't see how Congress can effectively argue that all businesses should be required to cover their employees or pay into a pool. Not with the conditions many businesses operate in today. (I do think big employers will continue to cover workers,or pay part of their insurance, as a way to attract them.)

2. So, I go to option three. There are several advantages to making the individual responsible for getting their own insurance.

For example, no longer would your insurance be tied to your job. Fewer workers would get locked in a job they hate solely to keep their health benefits. There would be much more freedom.

Second, individuals could find packages that most fit their needs. That could benefit families.

Third, any individual-based system will come with a combo of federal subsidies/credits/deductions for working families to afford their premiums.

As part of this new system, either insurers should have to cover people with preexisting conditions or those people should have the means to get insurance somehow, somewhere. Also, there must be ample opportunities for states, associations, etc. to set up pools for people to join and purchase coverage.

The advantage of this approach is that individuals could still purchase health care through their employers, if their employers are among the firms that keep offering insurance. I tend to think we will evolve into some hybrid, where individuals buy their insurance but some companies still offer it.

Undoubtedly, the individual-based system will have its own problems. In another decade or so, we would be tweaking those. But I think this is is the wave of the future, more so than employer-based insurance.

3. I didn't argue for government insurance because the costs of insuring the 25-64 population through a Medicare-like system would be astronomical for taxpayers.

That said, I sure want to keep Medicare for seniors and Medicaid and CHIP for poor families, especially for young mothers.

Dublin Doctor Defrauds Medicare, Medicaid, Gets Four Years Probation For Health Care Fraud

Source: rockbridgeweekly.com

Acting United States Attorney Julia C. Dudley announced today that Dr. Linda Sue Cheek, age 59, of Dublin, Virginia, was sentenced yesterday in United States District Court for the Western District of Virginia in Roanoke for defrauding Medicaid and Medicare.

“These taxpayer-funded health care programs are designed to allow our friends and neighbors who are in need of medical care, the opportunity to obtain it,” Acting United States Attorney Julia C. Dudley said today. “When physicians like Dr. Cheek take advantage of these programs in order to get rich, it is our job to hold them responsible for their actions.”

Cheek was sentenced to serve four years of probation for her role in a scheme to knowingly and willfully defraud the Medicaid and Medicare health care programs for her own personal, financial gain. In February Cheek pled guilty to one count of health care fraud, admitting that she had been stealing from the two programs from January 2002 to March 2006.

In addition, Cheek was ordered to pay a total of $24,210.37 in restitution to Medicare and Medicaid and will be required to serve 600 hours of community service in a non-medical field. As part of her sentencing, her license to practice medicine was also revoked.

The defendant, who was a licensed physician by the Commonwealth of Virginia, operated New River Medical Associates, Inc. located in Dublin, Virginia. The facility operated primarily as a pain management and alternative medicine practice.

Cheek previously admitted that between January 2002 and March 2006 she submitted a series of false Medicare and Medicaid claims relating to her medical practice, including the practice of billing Medicaid and Medicare for services she had not performed.

In addition, Cheek admitted to billing Medicaid for services she claimed to perform herself that were, in fact, performed by one or both of the two nurse practitioners employed by New River Medical Associates. Cheek admitted that during many of these procedures she was out of the office and, at times, out of the country.

Finally, Cheek admitted to billing Medicaid and Anthem Blue Cross Beneficiaries for individual treatments called “cleansing sessions,” an investigational service. These “cleansing sessions” were performed and billed as regular, individual office visits but were carried out in a group setting. Medicaid, Medicare and other insurance providers do not allow medical professionals to bill for group sessions.

This case was investigated for the United States Attorney’s Office, Western District of Virginia by the Virginia Attorney General’s Medicaid Fraud Control Unit, the Internal Revenue Service, the U.S. Department of Health and Human Services, Office of Inspector General, the Virginia State Police Drug Diversion Unit and the Financial Investigation Unit of Anthem Blue Cross Blue Shield.

Assistant United States Attorneys Patrick Hogeboom and Charlene Day prosecuted the case for the United States.

Feds in Indy seek $789K from medical supplier

May 23, 2008. IndyStar.com

A lawsuit filed by the federal government in Indianapolis accuses a medical products supplier based in northeastern Illinois of falsely billing Medicare for $789,579 in medical equipment.

The government claims Criterion Medical Corp. of Braidwood, Ill. submitted 1,427 false claims between May 2002 and October 2007, billing the government for knee and calf replacement liners.

A government investigation determined those liners were not medically necessary and that Criterion acted recklessly.

The government seeks reimbursement and unspecified damages.

Attempts today to reach Criterion were unsuccessful.

Although the company has an active Web site, phone numbers listed for Criterion are disconnected.

The billings were for Medicare patients in Indiana.

Highmark Medicare Services to Begin Processing Claims in New Jersey

Posted on : 2008-05-22 | Author : Highmark Medicare Services News Category : PressRelease

CAMP HILL, Pa., May 22 NJ-Highmark-NJ-claims

CAMP HILL, Pa., May 22 /PRNewswire/ -- Highmark Medicare Services will begin processing Medicare Part A claims in New Jersey on September 1, 2008 and Part B claims on November 14, 2008. In October 2007, the Centers for Medicare & Medicaid Services awarded Highmark Medicare Services the Jurisdiction 12 (J12) Medicare contract to provide the Medicare Fee-for-Service Part A and Part B administrative services for the states of Pennsylvania, Maryland, New Jersey, Delaware and the District of Columbia. The award is part of a Congressional requirement to replace all current Medicare Part A and B contracts with new contract entities called Medicare Administrative Contractors (MACs).

In fiscal year 2007, Highmark Medicare Services processed about 48.8 million claims and served approximately 2.3 million beneficiaries and 57,000 providers. As the MAC for J12, Highmark Medicare Services is expected to process approximately 131 million claims annually, accounting for more than 11 percent of the national Medicare fee-for-service workload. Highmark Medicare Services will be working on behalf of approximately 4.2 million beneficiaries and 137,000 physicians and practitioners.

As a MAC, Highmark Medicare Services will serve as a single point-of-contact entity processing Medicare Part A and B claims from hospitals and other institutional providers, physicians and other practitioners within the J12 region. Highmark Medicare Services currently administers the Medicare Fee-for-Service Part A business for Pennsylvania, Maryland, and the District of Columbia, and the Part B business for Pennsylvania.

"As this work transitions from other contractors to Highmark Medicare Services, we are committed to making this as seamless as possible for Medicare beneficiaries and health care providers," said Patrick Kiley, president of Highmark Medicare Services. "We understand that one of the keys to accomplishing this is through timely and direct communications by the MAC and timely response by those who need to react to changes due to the transition."

If you have any questions related to the transition or Highmark Medicare Services, visit http://www.highmarkmedicareservices.com.

About Highmark Inc.

Highmark Medicare Services is a wholly owned subsidiary of Highmark Inc.

Highmark Inc. is a major force for Pennsylvania's economy. According to a Tripp Umbach study, Highmark has a $2.5 billion impact on the economy and that includes about 11,000 employees of Highmark in Pennsylvania. Overall, Highmark and its subsidiaries have 19,000 employees.

As one of the leading health insurers in Pennsylvania, Highmark Inc.'s mission is to provide access to affordable, quality health care enabling individuals to live longer, healthier lives. Based in Pittsburgh, Highmark serves 4.6 million people through the company's health care benefits business. Highmark contributes millions of dollars to help keep quality health care programs affordable and to support community-based programs that work to improve people's health. Highmark exerts an enormous economic impact throughout Pennsylvania. The company provides the resources to give its members a greater hand in their health.

Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

SOURCE: Highmark Medicare Services

© 2008 earthtimes.org.

Dealing with Medical Billing Errors

Submitted by Nicole Wilson on May 9, 2008 - 5:00pm

Medical billing errors may sound innocent; however, these so called mistakes may be just another way for either doctors or billing agencies to make some extra money. Filing false claims and double billing can be big trouble for the medical industry with the serious charge of fraud.

According to Medlaw.com a Michigan psychologist plead guilty for filing false claims with both insurance companies and Medicare. He was said to have filed $853,000 false claims.

Other doctors that commit this crime may double bill for procedures and doctor visits. They also will pad the bill with procedures they did not complete. The medical offices will defend that it is difficult to come up with the correct codes for appropriate billing to insurance and Medicare. It can also be difficult getting paid for honest claims that are not fraud they argue.

I was always under the impression that doctors were generally honest and that they mean well. I guess I wouldn’t have been so irked if it didn’t happen so often. My personal experience with billing errors has happened not once but five times in just the past couple of years. Since we have major medical and very little coverage we get to pay the majority of the bills. Doctor visits are not covered, so I always pay for the doctor visit up front.

The first time this happened was with a surgery for a lump that was removed. We paid the doctor visits with a credit card at the doctor’s office. A couple months later a bill for what we already paid for showed up in our mailbox. We talked with the accounting person in the office, and they were actually good about correcting this medical billing error.

The second time we had a medical billing error was when I had to go to registered dietician. They were so wonderful to have a pay up front before the doctor visit for the cash patients. They also took my insurance card, they insisted upon it, and I told them that my doctor visits are not covered. The service provided by the dietician was wonderful and helpful. But around 5 months later we receive a bill in the mailbox saying that we owed for the visits that we already paid for! What got tedious with this one was an intermediate medical billing company that didn’t answer their phone calls. I called the regular office, and they gave me the run around. Needless to say, I had to leave several messages on the billing offices machine to get anywhere. I finally got the problem straightened out, but both the doctor office and the billing office had no concern to fix the problem, unless they knew I was going to be calling them every single day for the rest of their lives. The problem did get resolved. But it really was annoying that I had to prove my innocence even though I paid for the visits up front.

The third time I encountered a medical billing error was at a different procedure for a biopsy. This time the insurance company gave a discount. They sent a statement for the allowed amount that the biopsy could be charged for and what part I was to pay. The office that did the biopsy sent the bill but it was over $200 when the allowed amount was only $40. I wrote a letter with the bill and sent a copy of the insurance paperwork and paid the correct amount. They never sent another bill after that. But I started to wonder how many people will pay the full price and never look at the other information sent by the insurance company.

The fourth time that I had a medical billing error was when I had to get an ultrasound done. This time the lab decided to pad the procedure with an additional ultrasound that they never did! I called the office up and had to explain that I did get the one ultrasound but not the other. The extra ultrasound that never happened was an additional amount of $280. I was happy that this time, they fixed the problem fairly quickly.

The fifth time that I have experienced this mysterious medical billing error was a bill that I had already paid for and have received another bill saying that they haven’t received payment. They cashed the check, and I have the copied check that I have mailed, faxed, and called them about. They have a medical billing agency too, and I first left a message but, no calls came back. So I faxed them and called them and got through to that person assigned to your bill. They assured me that they will not send the bill to collections and that it will take a bit of time to figure out. By now, after it being a regular thing these medical billing errors, I have lost my patients with the hours that I have to put into correcting them.

I haven’t had every single bill go this way. I will think twice about going back to those offices that I had these problems with in the first place. I don’t want to go through the headache again! If you have PPO you can shop around a little bit more than the dreadful HMO.

So the moral of the story is if I am just one individual that has encountered numerous medical billing errors, I would suspect that this is common practice and that there are a lot of individuals that are overpaying for their medical services. Since it is a fraudulent activity I would think that the medical billing offices would have absolutely no chance for medical billing errors.

Take your time and don’t be afraid to speak up if you do find a medical billing error. It is your hard earned money. I believe that doctors deserve what is fair and agreed upon and anything not completed or over billed is just wrong.

- by Nicole Wilson

Bill would regulate billing for patients' lab tests

By Margaret Stafford
THE ASSOCIATED PRESS
Sunday, May. 04 2008

KANSAS CITY — A bill before the Missouri House would prohibit doctors from
marking up the cost of certain anatomical laboratory work — such as skin
biopsies and Pap tests — that are performed by outside laboratories.

The bill, which has been approved by the Senate and is awaiting floor debate in
the House, would prohibit what's known as "pass-through" billing.

That's when a doctor sends a patient's test sample to an outside laboratory for
analysis. The lab charges the doctor a discounted price for the work, but the
doctor bills the patient's insurance or the patient a higher amount.

The extra amount is profit for the doctor, and most patients don't even know
what has happened.

"It seems to me that we should protect the patient from being charged (by a
doctor) for a service that someone else is doing," said Rep. Kevin Wilson,
R-Neosho, who is sponsoring the bill.

Opponents argue that the bill gets the state involved in pricing decisions that
should be left to private practice physicians and could hurt services for some
patients, particularly the uninsured.

The bill would require doctors or laboratories that actually perform the
anatomical services to directly bill insured patients.

Doctors who send the tests to labs could bill uninsured patients for the
services but could not increase the charges. The doctors would have to tell the
uninsured patients who performed the pathology services and the cost.

Nineteen states have passed bills that either require direct billing or
prohibit markup of pathological services. Medicare and Medicaid already have
prohibited doctors from marking up the cost of the anatomical laboratory work
they don't perform.

And the American Medical Association's code of ethics says no physician should
be paid for a service that he or she does not perform, or charge a markup on
services performed by others.

The law would reduce the potential for abuse even as doctors are ordering more
tests than ever for their patients, said Dr. Joseph Lombardo, a pathologist who
is medical director of hospital laboratories in the St. Charles area.

Lombardo said tests for skin cancer and prostate cancer, as well as procedures
such as colonoscopies, had grown dramatically in the past 10 years.

"The general population has never been, on such a broad scale, subjected to so
much testing and put at so much risk for markup charges," Lombardo said.

He cited a 1993 study by the Center for Health Policy Studies that found two
states that didn't have direct billing laws had 9.6 percent higher costs per
test and ordered 28.3 percent more tests than two states that did.

"Patients waiting on biopsy results and wanting to know if they have cancer
should not be exploited by markups," he said. "They need to know the lab doing
the work wasn't chosen for cost rather than quality."

But Dr. Arthur Freeland, a family practice doctor in Kirksville, said the bill
was a solution looking for a problem, at least in Missouri. Freeland is a vice
president of the Missouri Academy of Family Physicians, which testified against
the bill in the Senate.

Freeland said before the session that pathologists could not provide the
academy with any specific examples of unethical markups by Missouri doctors.

"It was sort of, 'This is probably happening in (Los Angeles) or somewhere,'"
he said. "It was that kind of response: 'It must be happening somewhere.'"

Missouri private practice doctors and their patients, particularly those in
small towns, would be hurt by the bill because it removes physicians'
discretion on pricing, he said. Most of Freeland's anatomical lab work is Pap
smears, and he currently negotiates a volume discount for the anatomical
services from a lab about 100 miles from Kirksville.

That arrangement reassures the lab that it will get paid, while assuring
patients that they are getting a good price, he said. Freeland said he had
often reduced the price for some cash-paying patients who needed the tests but
were concerned about costs.

"The lab has no appreciation for who has insurance or who is paying cash, but
patients know I've represented them to get the best price," he said.

Freeland said the markups on his tests were not for profit but to cover his
risk that a patient might not pay a bill.

EMS billing write-offs concern City Council

Randy Hanson Hudson Star-Observer
Published Thursday, May 01, 2008

Billing write-offs by St. Croix Emergency Medical Services will be back on the agenda when the Hudson City Council meets Monday night.

The news this time is expected to be better than what the council heard at its April 21 meeting.

At the meeting, council members were alarmed by a report that the ambulance service’s bad debt write-offs had equaled its revenue for the first quarter of 2008.

City Finance Officer Betty Caruso said Tuesday that the report was incorrect.

She said that around $189,000 might still be received of the $330,000 reported as having been written off as bad debt.

That still would leave $141,000 in write-offs for the first quarter, however.

The majority of write-offs are the result of Medicare and Medicaid paying significantly less for services than what is charged, according to Caruso.

She said Medicare pays a percentage of the bills. Medicaid pays a flat amount for specific services that covers even less of the actual expenses than Medicare, she said.

Caruso was hesitant to give any numbers, saying she still had work to do to come up with actual figures that she will present on Monday.

"Truly, we still need to keep looking at them." she said of the ambulance service. "They are very much at a break-even situation, as far as I am thinking. It’s hard for them. The type of runs that they’ve been running are expensive, and we’re writing them off."

The per capita rate that municipalities pay to fund St. Croix EMS was increased for 2008 to try to keep up with the costs.

St. Croix EMS serves the city of Hudson, the village of North Hudson, the town of Hudson and part of the town of Troy.

Doctor’s fraud totals $3 million, prosecutors say

By Scott MacKay

Journal Staff Writer - The Providence Journal

PROVIDENCE — Federal prosecutors are seeking $3 million from Dr. Tarek W. Wehbe, an internist with the Renaissance Medical Group in Providence, who the federal government accuses of fraudulently billing Medicare, Medicaid and private insurers for services he did not perform.

Wehbe, who had his license suspended last week by Rhode Island Health Director Dr. David R. Gifford, is accused of billing for services he didn’t perform, inflating the type of treatment he provided and billing for days consisting of more than 24 hours.

The complaint filed in U.S. District Court in Providence asserts that Wehbe billed for visits and treatments that, if performed properly, would have taken more than 24 hours in a single day. For example, Wehbe billed for 87 patient visits on March 7, 2006, according to the complaint. According to federal standards, the time needed to see that many patients would have been more than 30 hours.

On other days, the complaint alleges, Wehbe billed for 28, 27 and 23.6 hours of visits in a single day.

Federal prosecutors also say that Wehbe fraudulently billed for infusion of the drug Remicade, which is used to treat Crohn’s disease and rheumatoid arthritis, and for treatments with drugs such as Paclitaxel and Gemzar, which are used to treat cancer.

According to the affidavit, between November 2001 and December 2006, suppliers delivered 22,890 units of Remicade to the Renaissance Medical Group, which Wehbe owns. He billed insurers for 39,239 units, or about 16,000 more than he received. The complaint states that from 2002 to 2006, Medicaid, Medicare and private insurers overpaid Wehbe $2.99 million, of which $1.8 million went for infusion drug treatments and $1.1 million for fraudulent office visits and treatments.

Prosecutors are seeking forfeiture of Wehbe’s property and bank accounts. The affidavit states that Wehbe has an account at Citizens Bank and owns real estate at 1630 Mineral Spring Ave., North Providence; 566 East Shore Rd., Jamestown; 6 Pine Tree Lane, Lincoln, 15 Dennell Drive, Lincoln; and 78 Farnum Pike, Smithfield.

Along with the U.S. Attorney’s office, other agencies involved in the investigation include the U.S. Department of Health and Human Services, the Internal Revenue Service, the U.S. Food and Drug Administration and the Rhode Island attorney general’s Medicare fraud control and patient abuse unit.

Wehbe, 43, has been under investigation by state and federal agencies for alleged health-care fraud and medical negligence since a raid at his office in December 2006. When the state suspended Wehbe’s license on April 7, Gifford, state health director, used his power to pull a doctor’s license without a hearing if a physician is deemed to be an immediate danger to the public.

That suspension was prompted by the discovery that Wehbe’s records of purchases of chemotherapy drugs did not match the amount he billed insurance companies. “In reviewing the records, it doesn’t appear that he could have given what he billed for,” said Dr. Robert S. Crausman, chief administrative officer for the state Board of Medical Licensure. “That could be just billing fraud but it leaves open the possibility that patients didn’t get what they should have gotten.”

Most of the affected cancer patients left Wehbe’s practice in December 2006 after he agreed to stop offering infusion therapy at his office after the investigation started, Crausman said. At the time, investigators were concerned about his treatment of patients who had rheumatoid arthritis, hepatitis C and fibromyalgia. When the cancer treatment issue came to light, the medical board considered the matter more serious and recommended that Gifford immediately pull Wehbe’s license, according to Crausman.

The state attorney general’s office is following up to determine if there was abuse of patients, said spokesman Michael Healey.

smackay@projo.com

Big Sentence for Medicare Fraudster

April 03, 2008 02:59 PM ET | Luke Mullins

Rita Campos Ramirez, a 60-year-old Miami resident, received a 10-year prison sentence for her role in a multimillion-dollar Medicare fraud scheme. The $170 million scheme is the program's largestindividual case of fraud ever. The sentence was announced Wednesday.

As part of her punishment, Ramirez will also have to hand over her three homes and a car. Plus, she was ordered to pay $105 million in restitution to the federal government.

"The sentence in this case dispels the myth that white-collar-crime defendants get off lightly," FBI Special Agent in Charge Jonathan Solomon said in a press release. "It reinforces the message that healthcare fraud—stealing from U.S. taxpayers—is a serious crime."

Details of the crime:

Campos pleaded guilty on Aug. 28, 2007, to one count of conspiracy to commit health care fraud and one count of submitting false claims to Medicare. As part of her plea, Campos admitted that between October 2002 and April 2006 she owned and operated R&I Medical Billing Inc., a medical billing company that specialized in submitting bills to the Medicare program on behalf of HIV infusion clinics. Campos admitted that she knowingly submitted approximately $170 million in fraudulent medical bills to Medicare on behalf of 75 HIV infusion clinics in Miami-Dade County that were part of the scheme. Infusion clinics serve HIV patients by providing prescribed medications intravenously.

The Medicare program paid approximately $105 million of the $170 million in fraudulent bills submitted by Campos, with Campos personally receiving $5 million for her role in the fraud.

Full press release is here.