Health Care Fraud Blog

OIG Issues Special Fraud Alert - PODs "Inherently Suspect"

Tue, 26 Mar 2013 20:21:48 -0500

WASHINGTON (March 26) – The Office of the Inspector General of the Health and Human Services Department has issued a Special Fraud Alert that physician-owned distributorships (PODs) are “inherently suspect” under the anti-kickback statute (AKS) and has listed suspicious characteristics that may increase the risk of fraud and abuse.
The alert focused on physician-owned businesses / PODs that obtain revenue from selling implantable medical devices ordered by their physician owners to use in procedures they perform on their patients at hospitals or ambulatory surgical centers.

“The opportunity for a referring physician to earn a profit, including through an investment in an entity for which he or she generates business, could constitute illegal remuneration under the anti-kickback statute,” said the IG alert .

One purpose of the anti-kickback statute (AKS) is to protect patients from inappropriate medical referrals or recommendations made by health care professionals who may be unduly influenced by financial incentives. It a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce, or in return for, referrals of items or services reimbursable by a Federal health care program. When remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the AKS is violated. Parties on either side of an impermissible “kickback” transaction are exposed to criminal liability. Violation of the AKS statute is a felony punishable by up to 5 years imprisonment, a maximum fine of $25,000 or both. Individuals convicted of violating the AKS are excluded from Federal health care programs, including Medicare and Medicaid. OIG also has the right initiate an administrative action to exclude persons from the Federal health care programs or to impose civil money penalties for fraud, kickbacks, and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act.

The financial incentives that PODs offer to their physician owners may influence them to perform medically unnecessary procedures and to use the devices the PODs sell instead of other more appropriate devices.

According to the Special Fraud Alert, the OIG is “particularly concerned about the presence of such financial incentives in the implantable medical device context because such devices typically are ‘physician preference items,’ meaning that both the choice of brand and the type of device may be made or strongly influenced by the physician, rather than being controlled by the hospital or ambulatory surgical center where the procedure is performed.”

If you or someone you know has been accused of violating the anti-kickback statute, for serious health care fraud defense, contact attorney Robert Malove (954)861-0384.

Convicted Houston Doctor Sentenced to More than 5 Years Behind Bars

Wed, 13 Mar 2013 16:14:33 -0500

HOUSTON (March 13) - A Texas doctor who was convicted of conspiracy to commit health care fraud and six counts of false statements relating to health care matters was sentenced today to serve 63 months behind bars.

Ben Harris Echols, 63, of Houston, was convicted late last year of conspiring to commit health care fraud by falsifying plans of care for Medicare beneficiaries, including patients whom he did not treat, as part of a $17.3 million Medicare fraud scheme. Upon completion of his prison term, Echols was ordered to serve three years of supervised release and pay restitution in the amount of $2,918,830.

According to evidence presented at trial, Echols signed plans of care for Medicare beneficiaries who were not under his care and about whose conditions he had no knowledge. In many instances, Echols signed plans of care even though other doctors were listed as the attending physician on the documents.

Echols was prosecuted by the Medicare Fraud Strike Force, supervised by the Criminal Division's Fraud Section and the U.S. Attorney's Office for the Southern District of Texas.

If you or someone you know is facing prosecution as a result of aggressive law enforcement activity in the area of Medicare or Medicaid fraud, call Board Certified Criminal Trial Lawyer Robert Malove, co-author of the noted treatise, White Collar Crime: Health Care Fraud (Thompson West 2012-2013 ed.)

Deputy AG Lanny Breuer Leaves Justice Department

Wed, 30 Jan 2013 16:58:47 -0500

Washington (Jan. 30) -- Assistant attorney general of the Criminal Division, Lanny Breuer, is leaving the Justice Department. Breuer gained notoriety for defending president Bill Clinton against impeachment and for defending four-time Cy Young award winner, Roger Clemens.

"Serving as assistant attorney general for the Criminal Division has been the greatest privilege of my professional life," Breuer said in a statement. "From my first day on this job nearly four years ago, I have loved it, and I am so proud of what the Criminal Division has accomplished over the past four years," Breuer said.

The announcement came the day after a federal judge in New Orleans approved the largest package of criminal fines and penalties in U.S. history. In 2010, Attorney General Eric Holder had named Breuer to oversee the Deepwater Horizon Task Force. The record amount of the settlement in the guilty plea will cost BP $4 billion and lets Breuer to depart the Justice Department on a positive note.

Many have criticized Breuer for failing to bring major prosecutions against the nation's largest financial institutions responsible for financial crisis in 2008 and 2009. Breuer maintained that the banks and their employees needed to be protected against an implosion that could cause greater problems.

Breuer was the top administration official who faced criticism for ATF's Operation Fast and Furious. Breuer ultimately apologized for an inaccurate letter to a senator in which the Justice Department denied the ATF allowed guns to be smuggled to Mexican drug cartels.

Medicare Fraud Strike Force Arrests 91 - 33 in South Florida

Thu, 04 Oct 2012 15:07:14 -0500

WASHINGTON, D.C. (October 4,2012) Today, U.S. Attorney General Eric Holder and U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced at a joint press conference that Medicare Fraud Strike Force operations conducted one of the largest health care fraud takedowns in history.

Charges have been brought in seven cities from Brooklyn to Los Angeles against 91 individuals – including doctors, nurses, and other licensed medical professionals – for their alleged participation in fraud schemes involving nearly $430 million in false billings.

Charges include health care fraud, conspiracy to commit health care fraud, wire fraud, violations of the anti-kickback statutes, aggravated identity theft, and money laundering charges are based on a variety of alleged activities involving treatments and services that were medically unnecessary or never actually rendered.

The alleged fraudulent schemes range from home health care and mental health services, to psychotherapy, physical and occupational therapy, durable medical equipment services, and the largest ambulance fraud scheme ever prosecuted by the Medicare Fraud Strike Force.

The joint press release by the Department of Justice and Department of Health and Human Services announced that "in Miami, a total of 33 defendants are charged for their alleged participation in various fraud schemes involving a total of $204.5 million in false billings for home health care, mental health services, occupational and physical therapy, and DME.

In one case, three defendants are charged for participating in a fraud scheme at LTC Professional Consultants and Professional Home Care Solutions Inc. which led to approximately $74 million in fraudulent billing for home health care."

In another South Florida case, according to the indictment, the owners and operators of Hollywood Pavilion, psychiatric hospital, have been charged with paying cash kickbacks to owners and operators of assisted living facilities and halfway houses to obtain patients, and then billing Medicare for over $67 million in mental health services that were unnecessary or never even provided. The indictment alleges a scheme that is not new to South Florida and will feature a number of government witnesses who have previously testified in some of those cases.

In another Miami case, the government is restraining 40 bank accounts, and 16 residences valued at approximately $4.6 million, that belong to the owners and operators of a home health agency charged with defrauding Medicare to the tune of approximately $74 million.

Psychiatrists Sentenced to 10 Years in Prison for Medicare Fraud

Mon, 01 Oct 2012 23:04:43 -0500

MIAMI, FL - A Weston psychiatrist was sentenced on Monday to 10 years in for his role in what United States Department of Justice Health Care Fraud Strike Force prosecutor Jennifer Saulino called "one of the largest and most brazen health care fraud conspiracies in recent memory."

Dr. Mark Willner, who practiced in Fort Lauderdale and Boca Raton, was convicted of conspiracy to commit health care fraud after a six-week trial earlier this year. Prosecutors said Willner, 56, was part of a broader conspiracy involving American Therapeutic Corp., which billed the taxpayer-funded Medicare program for more than $205 million in fraudulent claims.

In her submission to U.S. District Court Judge Patricia Seitz, United States Department of Justice Heath Care Fraud Strike Force prosecutor Jennifer Saulino wrote "This massive fraud was committed by manipulating the proper treatment of Alzheimer's and dementia patients, substance abusers seeking treatment, and others convinced or cajoled into spending time at ATC."

"Without Willner and other doctors signing thousands of false and fraudulent patient documents – documents that stated he was personally directing the patients' treatment plans and having 'face-to-face' contact with the patients – ATC could not have succeeded on such an immense scale," Saulino wrote.

Psychiatrist Dr. Alberto Ayala, 68, of Coral Gables, who was also convicted at trial was sentenced to 10 years in federal prison. Willner's attorney, Sam Rabin, said he intends to appeal.

Dr. Alan Gumer, M.D., who after being unable to post his own $1 million bond to secure his release from jail following his arrest, was one of the witnesses the government called to the witness stand to testify at trial. After at least five debriefings with prosecutors in the week after his arrest, Gumer's bond was cut in half before he could be released.

Rabin's cross-examination of Gumer at trial was classic. Even Judge Seitz at one point referred to Rabin as "the honorable Mr. Rabin." Attorneys interested in learning about how to cross-examine a cooperating witness would do themselves a service by studying (as have I in preparation for a pending Medicare fraud case) Mr. Rabin's, and Miami criminal defense attorney extraordinaire, Jose Quinon's cross of Gumer.

Gumer was into bookies for gambling debts and hadn't paid federal income taxes for at least 10-years. Yet despite the clear implication that Gumer's cooperation was all about saving his own neck and that he would have said just about anything on the stand in hopes of earning a significant sentencing reduction at the government's request, in the end the evidence proved to be too much for the defense to overcome.

Prosecutors said Dr. Willner and Dr. Ayala caused false and fraudulent claims to be submitted to Medicare for partial hospitalization programs.

According to prosecutor Saulino, "These co-conspirators, including Dr. Willner, victimized the most vulnerable members of our society so they could have nicer homes and fancy artwork."

More than 30 people have been charged and more than half have pleaded guilty or been convicted at trial. Last year, Lawrence Duran, the president of ATC was sentenced by U.S. District Judge Lawrence King to 50-years behind bars; ATC vice-president Judith Negron was sentenced
to 35 years. Dr. Gumer also testified at Negron's trial.

Woman Earns Sentence Reduction for Helping Feds Convict Brother

Sat, 29 Sep 2012 21:20:58 -0500

BATON ROUGE, La. (AP - Karen Rayburn, a 47-year-old Baton Rouge woman, who worked as a patient recruiter for several Louisiana durable medical equipment (DME) companies has been sentenced to 18 months in prison for her role in a Medicare fraud scheme. Rayburn pleaded guilty to one count of conspiracy to commit health care fraud In January.

The companies linked to the scheme allegedly submitted more than $21 million in bogus Medicare claims. Prosecutors say bogus prescriptions for leg braces, wheel chairs and other equipment that Rayburn obtained were used to submit fraudulent claims to the Medicare program.

The United States Probation office conducted a Pre-Sentence Investigation and determined that Rayburn's advisory guidelines offense level was 23 with a criminal history category of I. Her advisory guideline imprisonment range is 46 to 57 months.

Noting that Rayburn had provided "substantial assistance" in the investigation or prosecution of others involved in the conspiracy, the prosecutor filed a §5K1.1 motion under the guidelines urging the judge to reduce Rayburn's sentence by 40%.

The prosecutor wrote, "While the United States would typically recommend a five (5) level reduction in a matter such as this, the result would be a advisory guideline range of 27 to 33 months, which would result in a recommended sentence for Ms. Rayburn that is much more severe than the sentence imposed by this Court for her own brother, Rodney Taylor, who did not cooperate. Such a sentence would also be approximately the same as that imposed by this Court on at least one recruiter who pled guilty in two separate matters and admitted to conduct in a third matter, yet who did not cooperate."

Eight other defendants have been sentenced for their roles in the plot. Three others await sentencing.

Two Home Health Care Agency Owners and Two Docs Among Nine Busted for Paying and Receiving Kickbacks for Medicare Patient Referrals

Fri, 28 Sep 2012 18:04:48 -0500

CHICAGO (September 25) - Two owners of Rosner home health care agency near Chicago and two physicians were among nine people charged in a 27-count indictment with federal offenses for paying and receiving kickbacks in exchange for the referral of Medicare patients for home health care services.

Three defendants were charged with one count of conspiracy to pay illegal kickbacks for Medicare patient referrals. Eight of the nine defendants were charged with two or more counts of violating the anti-kickback statute.

According to the indictment between January 2008 and July 2012, three defendants conspired with others to pay kickbacks and bribes to doctors. The amount of kickbacks varied from $300 to $600 for each new patient’s completion of five home health visits in one cycle and ranged between the same amounts for the repeat admission of a previous patient in a new cycle of home health care.

Medicare paid the HHCA approximately $13 million for claims submitted for home health services between January 2008 and January 2012.

Conspiracy and each count of violating the anti-kickback statute carry a maximum penalty of five years in prison and a $250,000 fine. If convicted, the court must impose a reasonable sentence under federal statutes and the advisory United States Sentencing Guidelines.

7 Doctors and Pain Clinic Owners Arrested in Pill Mill Crackdown

Thu, 16 Aug 2012 23:50:04 -0500

WESTON, FL (August 16 ) - At a news conference at DEA offices in Weston, FL, on Thursday regarding in the latest crackdown on South Florida pill mills - Phase II of the two-year Operation Pill Nation - it was announced that, seven doctors, three pain clinic owners at the Pompano Beach Medical Corp., and one owner's relative have been arrested for crimes including racketeering, trafficking in a controlled substance, money laundering among others.

The allegations are that beginning in April 2010 and continuing up until as recent as last month, undercover investigators visited the clinic and were prescribed controlled substances despite the fact that none of the agents were suffering from any infirmity that required medication.

"The DEA does not target doctors; we target drug traffickers," DEA Special Agent in Charge Mark Trouville said.

Among those arrested were: Dr. Marcia Sills, 59, of Fort Lauderdale; Dr. Gabriel Sanchez, 74, of Tamarac; Dr. Mark Cukierman, 56, of Boca Raton; Dr. Michael Fronstin, 75, of Palm Beach Gardens; Dr. Adeline Essian, 59, in Chicago; and Dr. Khanh Van Kim Duong, 33, in New York. Dr. Thomas Rodenberg, 53, of Fort Lauderdale, was being sought in Tennessee. Also arrested were clinic owner Steven August Edson, 40, of Coral Springs; Bruno Balbi, 29; Francisco Carlos Balbi, 57; and Aline Balbi Leca, 31, all of Deerfield Beach.

"[If] these folks [are] hiding behind a white jacket and diploma, it doesn't give them a pass," Trouville said.

According to Trouville, "[t]hese folks are simply doing this for profit and greed. There's no intent for good medical practice there."

Broward Sheriff Al Lamberti said, "I still don't get it. A doctor goes to medical school for 10 years to learn how to save lives and ends up ruining lives and that's something we just can't tolerate."

According to Lamberti, two years ago "there were 78 McDonald's and there were 130 pill mills. But I'm happy to say today that you have a better chance of buying a Big Mac than you do a bottle of oxycontin."

To watch a video clip from the news conference, click here.

$20 MILLION HEALTH CARE FRAUD SCHEME NETS TWO OF MIAMI HOME HEALTH COMPANY OWNERS MORE THAN SIX YEARS IN PRISON

Sat, 23 Jun 2012 17:03:20 -0500

MIAMI (June 21) - Two Miami home health care agency owners of a were sentenced to 73 and 74 months in prison for their participation in a $20 million home health Medicare fraud scheme.

Ariel Rodriguez was to 73 months in prison and three years of supervised release and Reynaldo Navarro was sentenced to 74 months in prison followed by three years of supervised release and were ordered to pay $14 million in restitution. Rodriguez, 41, Navarro, 37, were the owners of Serendipity Home Health Inc., a Miami home health agency that was supposed to provide home health care and physical therapy services to qualifying Medicare beneficiaries.

According to court records, Rodriguez and Navarro paid kickbacks and bribes to patient recruiters in exchange for the recruiters providing patients to their home health care agency, as well as prescriptions, plans of care and certifications for medically unnecessary therapy and home health services for Medicare beneficiaries. The prescriptions, POCs and medical certifications were then submitted to Medicare for reimbursement.

Court documents claimed nurses and office staff falsified patient files for Medicare beneficiaries to make it look as if the beneficiaries qualified for home health care and therapy services. Rodriguez and Navarro knew that the beneficiaries did not qualify for and did not receive such services, but these files were falsified nevertheless so that Medicare could be billed.

Rodriguez, Navarro and their co-conspirators submitted almost $20 million in false and fraudulent claims to Medicare, of which Medicare paid approximately $14 million.

JUDGE GRANTS DOWNWARD DEPARTURE FOR PHARMACIST

Thu, 21 Jun 2012 15:14:46 -0500

TAMPA (June 21) - Today, U.S. District Court Judge Virginia Hernandez Covington granted the defendant's motion for a downward variance from the sentence recommended by the advisory United States Sentencing Guidelines. As I sat in court and listened, I could not help but be very impressed with Judge Covington's keen insight into the application of the sentencing guidelines.
The defendant, Paul Vincent Rivers, was a pharmacist who twice sold oxycodone to a confidential informant. The advisory United States Sentencing guidelines called for a sentence of 46 - 57 months incarceration. In pronouncing sentence, Judge Covington recognized how the defendant never knew his father and was raised by his mother - which was certaintly no easy task, and that the defendant had served in the U.S. military.

Federal judges are required to take the U.S. Sentencing Guidelines into consideration when fashioning a sentence that is sufficient, but not greater than necessary. In ruling with respect to the sentence, Judge Covington said that the fact that the defendant had suffered the permanent loss of pharmacist's license and was now a convicted felon merited a downward variance from the guidelines recommended sentence and slashed it almost by 50% down to 24 months imprisonment.

Judge Covington's sentencing analysis and judicial independence are no doubt to be commended. Many judges reflexively impose the sentencing guide lines strictly without looking to other factors. Since the guidelines are advisory, one could hope to see more positive deviations from the guidelines. Here, one could argue that even a term of probation with a period of house arrest with an electronic monitor under these circumstances would have been sufficient and not greater than necessary.

Detroit-Area Patient Recruiter Pleads Guilty

Sun, 22 Apr 2012 20:43:38 -0500

WASHINGTON – A Detroit-area patient recruiter pleaded guilty today for his participation in a Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Daron Elder, 28, of Southfield, Mich., pleaded guilty in the Eastern District of Michigan to one count of conspiracy to commit health care fraud. At sentencing, he faces a maximum penalty of 10 years in prison and a $250,000 fine. However, the advisory sentencing guidelines call for a term of imprisonment of 30-37 months, restitution in the amount of almost $3 million, plus a $1 million fine.

According to the plea documents, Elder was a patient recruiter for a medical clinic in the Detroit area, Blessed Medical Clinic. Elder paid indigent Medicare beneficiaries cash kickbacks to receive diagnostic tests that he knew were medically unnecessary. In return for the cash kickbacks, the Medicare beneficiaries allowed their identification to be used in the submission of fraudulent claims. The government will argue at sentencing that Elder’s conduct caused the submission of approximately $2.5 million dollars in fraudulent claims to Medicare.

N.J. Doctor Sentenced to Two Years in Prison for Health Care Fraud

Sun, 15 Apr 2012 09:25:09 -0500

NEWARK, N.J. – Dr. Michael P. Stein, 63, a New Jersey doctor, was sentenced today to 24 months in prison for defrauding Blue Cross Blue Shield for approximately three-quarters of a million dollars by submitting false claims for services never performed.

Between August 2004 and September 2010 Stein owned and operated Randolph Otolaryngology. Stein purportedly treated a patient with the initials J.F. for nasal problems and billed Blue Cross Blue Shield for the services.

However, investigators determined that Stein submitted fraudulent claims with Blue Cross Blue Shield for procedures that were not performed. Evidence revealed that Stein submitted claims for approximately 900 nasal endoscopies he purportedly conducted, when only a few were actually performed. Stein also admitted he filed false claims for office visits and medical procedures that occurred while he was out of the country on vacation.

Blue Cross Blue Shield paid Stein $725,156.45 from as a result of the fraudulent false claims submitted, and, under the plea agreement, Stein agreed to pay restitution and forfeiture for the entire amount.

In addition to the prison term, restitution and forfeiture, Stein was ordered to serve three years of supervised release. His medical license has been surrendered.

Medicare Fraud Cases on the Rise

Wed, 21 Dec 2011 15:43:41 -0500

Medicare Fraud Cases on The Rise

http://gooznews.com/?p=3453

By GoozNews

Federal prosecutors brought a record number of cases of health care fraud in fiscal 2011, a new report said, with Florida and its huge Medicare-dependent population remaining the epicenter of fraudulent claims.

The latest data, drawn from federal records by the Transactional Records Access Records database at Syracuse University, showed total prosecutions jumped 68.9 percent to 1,235 cases compared to 2010, a record increase.

The huge increase was fueled largely by a sharp jump in cases brought in Puerto Rico, where prosecutors charged 548 defendants with health care fraud last year, up from just 119 the previous year. Most of those were minor cases. But even without the Puerto Rican cases, fraud prosecutions nationwide were up sharply and reached the highest level since 2000.

Miami led the nation in activity, accounting for nearly one out of every nine health care fraud prosecutions, followed by Houston. Together, federal prosecutors in those two districts accounted for over one out of every five health care fraud prosecutions.
“The good news is
there’s lots of prosecutions.

The bad news is there’s

lots of prosecutions.”

The Obama administration stepped up its enforcement activity in late 2009 with the creation of tasks forces in nine cities to root out Medicare and Medicaid fraud. “They’re really going after these cases very aggressively, and I think you’ll see prosecutions increase even more over the next few years,” said Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association, which was launched in 1985 by insurers to help root out both private and public sector fraud in the industry.

“The good news is there’s lots of prosecutions,” he said. “The bad news is there’s lots of prosecutions. The real question is what will CMS (the Center for Medicare and Medicare Services) do to prevent these frauds from taking place in the first place.”

A typical case concluded in Trenton last week when a federal judge sentenced a former senior manager of Columbia, Md.-based Maxim Health Care Services, one of the nation’s leading home health care providers, to five months in prison for setting up a phony office that billed Medicaid and the Veterans Administration nearly a million dollars. The criminal charges were part of a nationwide investigation of Maxim that led in September to an out-of-court settlement where the firm – to avoid a conviction that might have disqualified it from the programs – agreed to pay the government $150 million in criminal and civil penalties.

Experts and even defense attorneys say health care fraud, estimated to cost the government $70 billion a year, won’t be curbed until the government figures out how to short-circuit schemes through better monitoring of claims before they are paid and better screening of firms before they are allowed to sell services to the programs. Last June, CMS launched a data-mining program that will review Medicare claims before payment to identify individual providers that show huge spikes in activity. “CMS is on the right track,” Saccoccio said.

“They have to blow up the bill now, investigate later system,” agreed Andrew Ittleman, a white collar criminal defense attorney at Fuerst Ittleman in Miami. While he says that many cases involve companies in legitimate billing disputes with the government, he agreed “it’s not at all misguided given the size of the problem and the magnitude of the fraud.”

“The more sinister cases down here involve people who set up broom closets without an address and bill Medicare as long as they can before they high-tail it to Cuba or wherever in Latin America,” he said. “Magistrates aren’t even giving pre-trial release to some of these defendants because we don’t have an extradition treaty with Cuba.”

This story appeared first in The Fiscal Times.

Senators want better assessment of Medicare fraud detection program

Wed, 21 Dec 2011 15:39:59 -0500

BY JOSEPH MARKS 12/20/2011

Medicare officials should better evaluate whether a new system designed to spot fraudulent claims and roll back the program's roughly $50 billion in annual improper payments is living up to its potential, a bipartisan group of senators said Tuesday.

The Centers for Medicare and Medicaid Service responded that it had been measuring results from the $100 million system since soon after its July launch and would update Congress on the results soon.

"The predictive modeling program is well on its way to achieving the kind of results CMS expected," agency officials said.

CMS plans to launch the new system nationwide this summer. But without clear metrics to gauge successes and failures neither the agency nor Congress will be able to determine whether the program is doing what it's supposed to, the senators said in a letter to Peter Budetti, director of CMS' Center for Program Integrity.

"As is often said, one cannot manage what one cannot measure," Sens. Tom Carper, D-Del.; Scott Brown, R-Mass.; and Tom Coburn, R-Okla.; said. Carper is chairman of the Senate Homeland Security Subcommittee on Federal Financial Management, which oversees CMS' financial issues. Brown is that panel's ranking Republican and Coburn, a physician, is a subcommittee member.

The predictive analysis tool was designed to flag common patterns of Medicare fraud such as suspicious billing patterns or a great distance between the hospital where treatment occurred and the claimant's home address. The plan is for CMS officials to halt those payments and immediately investigate them for possible fraud.

Legislative requirements that most Medicare claims be paid within 30 days traditionally has meant that CMS paid out claims before investigating them -- what officials call the "pay and chase" model.

The senators' letter concludes with a list of 10 questions focused on how much money the tool has clawed back, what lessons CMS officials have learned from the system's implementation so far, and whether those lessons have changed how the agency pays claims and which Medicare services providers it contracts with.

The predictive analytics program is similar to several fraud detection tools used by the Recovery Accountability and Transparency Board, which tracks spending on President Obama's $840 billion stimulus bill. That program has kept stimulus money lost to fraud at below 1 percent compared with a rate of up to 7 percent for government spending generally.

Plans to roll out similar tools on a governmentwide basis are working their way through Congress and the White House.

Read more at : http://www.nextgov.com/nextgov/ng_20111220_7934.php?oref=topnews

Miami Medicare Fraud: Medicare fraud bill reintroduced

Wed, 21 Dec 2011 15:37:02 -0500

From the Miami Herald Blog:

Medicare fraud bill reintroduced U.S. Rep. Ileana Ros-Lehtinen, R-Miami, has reintroduced legislation that would double the fines and jail time for people convicted of Medicare fraud. It also creates a new criminal offense punishable with a 10 year minimum sentence for those who knowingly sell or distribute the ID numbers of Medicare beneficiaries. The legislation also bars those who have been part of Medicare fraud in the past from billing Medicare if they switch companies. It also facilitates real-time information sharing among law enforcement agencies to aid in uncovering and dismantling Medicare scams. "South Florida has been known as the epicenter of Medicare fraud for years," she said. "It is time we took the fight to those who seek to defraud Medicare and prey on our most vulnerable citizens. This bill not only increases the penalties for those who engage in Medicare fraud, but also sets up a pro-active paradigm that will help stem the tide of abuse in South Florida and across the nation." The bill takes particular aim at Medicare theft in Miami-Dade County, widely regarded as the nation's capital of healthcare fraud. Medicare fraud in South Florida costs taxpayers between $3 billion and $4 billion every year, according to law enforcement and healthcare officials. Nationwide, Medicare and other healthcare fraud is estimated to cost $68 billion annually.

Read more here: http://miamiherald.typepad.com/nakedpolitics/2011/12/medicare-fraud-bill-reintroduced.html#storylink=cpy