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50 And 35 Year Prison Sentences Handed Out In Medicare Fraud Case

A Judge in Miami has sentenced two former officers of a Miami based mental health therapy company to 50 ane 35 years in prison; making the sentences two of the largest ever for Medicare Fraud. The sentences reflect a trend of increasingly strong punishment for Medicare Fraud; however it also may reflect how treacherous guilty pleas can be in federal court.

In this case, the two defendants pled guilty without a trial and without a plea agreement with the government.  In federal criminal prosecutions, defendants who plead guilty generally do so through plea agreements with prosecutors.  However, there are occasions where such an agreement waives appeal rights or commits a defendant to agree to facts they may not be comfortable with, including in many cases, the level of involvement in the crime or the amount of money at issue.

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Medicare Increases Fraud Enforcement

Fraud detection and suppression measures related to Medicare that were placed into the federal budget last year become effective this month. These include the ability of Medicare to stop payment of suspected claims rather than making payments and then investigating those claims and increased funds, almost $350 million, toward Medicare program integrity.  According to CMS a substantial focus will be on matters receiving some recent attention such as Home Health and medical equipment providers.

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Government recoups over $4 Billion from health care providers

ABC News has reported that “the Department of Health and Human Services(HHS), in a joint effort with the Justice Department, recouped more than $4 billion through fraud prevention and enforcement efforts in fiscal 2010, officials announced this week.”

“Our aggressive pursuit of healthcare fraud has resulted in the largest recovery of taxpayer dollars in the history of the Justice Department,” U.S. Associate Attorney General Thomas Perrelli said in a statement.

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Home Health Continues To Be A Medicare Focus

Home Health, particularly the prescribing of home health services has received substantial scrutiny over the last two years. Initiatives focusing on home health agencies has brought about large overpayments as well as agencies effectively run out of business through pre-payment review.  Now the criminal prosecutions are catching up to the administrative action.

Recently eight nurses were sentenced for their roles in a Medicare fraud scheme.  According to the government, the nurses falsified medical records to qualify patients for home health care services the patients did not need.  Under Medicare guidelines, a patient does not qualify for home health services unless that patient is homebound and incapable of performing certain functions. 

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Miami Still First In Medicare Fraud

Federal authorities arrested 111 people, one third from Miami, for Medicare faud offenses, “Miami remains ground zero for healthcare fraud,” Gillies said at the U.S. Attorney’s office press conference.”

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The Next Wave? Medicare Fraud Investigation Targets Mental Health Programs

Medicare fraud proseuctions often seem to go in cycles.  To anticipate a cycle, there are four things you look for.  The first is the easiest, the Office of Inspector General (OIG) comes out with a work plan each year that details areas the federal government intends to focus on.   Second, of one or more of those focus areas a large number of providers in the particular service area will begin to receive  a wave of administrative scrutiny such as requests for records and  overpayments and then there will be a large, high publicity arrest of a provider in that area.   Third, the scrutiny is generally a topic that had a previous wave of prosecutions years earlier that slowed down after a large number of prosecutions followed by regulatory changes that dried up the fraud landscape.  Fourth, it happens in South Florida; because Florida is the epicenter of Medicare fraud. 

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The Curious Case Of The Patient Purchasing Doctor

In a curious interesting article out of Lakeland, Florida, we have the case of a physician who it appears purchased a medical practice from another group, then learned that many of the patients of the practice he was purchasing were drug seekers and doctor shoppers.  He then helped law enforcement arrest a number of the patients.   

While it seems this is a nice story about a doctor assisting law enforcement to stop doctor shopping, there are a couple of issues raised by the article that appear a bit strange.  First, there is a curious line in the article “ he could have canceled the contract with Mathis’ company, but because he only had to pay for legitimate patients, he decided to keep his contract and help law enforcement.” 

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Phyisician Identity Theft Causes Medicare Headaches

The downside of the Information Age is that a large amount of personal information is easy to access and use for nefarious purposes.  Unwinding the resulting  fraudulent activity can be frustratingly difficult,whether it be credit cards, banking, check or credit information.

Physicians participating in Medicare face similar identity theft headaches.  There are several types of physician identity theft.  One is when identity thieves take over a physician’s provider number, fraudulently adding a new practice address and billing false claims. Physicians occasionally learn of this type of fraud much later; after receiving a 1099 form from CMS indicating the physician has received vastly more reimbursement than he or she claimed at their own practice.   Another way a physician learns is the eventual receipt of a large overpayment for claims that physician never submitted.

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