South Texas Health Care Providers Remain Under Considerable Scrutiny by HEAT Prosecutors and Investigators – Compliance Isn’t Optional – It’s Essential in 2011.
(January 6, 2011): Three Houston-area residents, one of whom is a physician, were sentenced to prison on January 4th for their roles in a multi-million dollar durable medical equipment (DME) Medicare fraud scheme. Each of the three defendants were also ordered to pay restitution to the Federal government, in amounts ranging from $29,052 to $1.4 million.
According to DOJ, a Houston-area DME company improperly billed Medicare for power wheelchairs and orthotic devices, beginning in 2003 and continuing until late 2009. In addition to the three co-conspirators sentenced today, a total of eight other individuals were convicted for their participation in the fraudulent scheme. One of the eight included the owner of the DME company.
At trial, Federal prosecutors were able to show that a variety of fraudulent actions had been taken by members of the group, ranging from the payment of illegal kickbacks to the prescription of medically unnecessary devices.
Notably, this was just the latest case investigated by members of the DOJ / HHS-OIG / MFCU Health Care Fraud Prevention and Enforcement Action Team (HEAT). This strike force is responsible for investigating and prosecuting cases throughout South Texas. As DOJ noted:
“Since their inception in March 2007, Strike Force operations in seven districts have obtained indictments of more than 850 individuals who collectively have falsely billed the Medicare program for more than $2.1 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.”
Both Federal and State investigators are aggressively targeting non-compliant providers. South Texas providers who take the time to review and update their current Compliance Plan should also conduct a gap analysis to better ensure that their operational and billing practices fully comply with applicable statutory and regulatory requirements.
Liles Parker attorneys have extensive experience representing health care providers in alleged Medicare overpayment and fraud cases. Should you have questions about our services, give us a call for a free consultation. We can be reached at 1 (800) 475-1906.
Health Care Fraud Enforcement Takes an International Turn
(October 17, 2010): The FBI has announced the arrest of 73 defendants, a number of which are allegedly members of an international organized crime organization, as part of one of the largest criminal health care fraud cases ever brought. It is estimated that these individuals are responsible for the illegal submission of over $163 million in fraudulent Medicare claims. As the FBI’s Press Release reflects:
“. . .the defendants allegedly stole the identities of doctors and thousands of Medicare beneficiaries and operated at least 118 different phony clinics in 25 states for the purposes of submitting Medicare reimbursements.
As the FBI noted, the schemes employed by this group included the submission of fraudulent claims for medically unnecessary treatments and services to the Medicare program for payment by these “phantom clinics.” Indictments covering these defendants were issued in five states, California, Georgia, New Mexico, New York, and Ohio. Commenting on the multi-agency cooperation involved, the Press Release notes that:
“Today’s arrests are an example of the FBI’s ability to conduct cross-program, multi-divisional investigations targeting a national level threat. In recent years, the department has undertaken a series of steps to modernize its organized crime program and enable federal law enforcement to take a unified approach to combating international organized crime. The Attorney General’s Organized Crime Council brings together the leadership of the FBI and eight other federal law enforcement agencies or offices with the department’s prosecutors, focusing high-level attention on these issues. The IOC-2 provides support in the form of information and intelligence to the member agencies that enhance efforts to identify, penetrate and dismantle the most dangerous organized crime groups through investigations and prosecutions. The creation of the International Organized Crime Targeting Committee and the Top International Criminal Organizations Target (TICOT) List, directs investigators and prosecutors to concentrate their limited resources on those international organized crime groups that pose the greatest threat to the United States. The department’s Criminal Division, through the Health Care Fraud Unit, Organized Crime and Racketeering Section, and the Asset Forfeiture and Money Laundering Section, has created new training programs to educate investigators and prosecutors on the intricacies of international organized crime and financial investigations.” (emphasis added).
Commentary: As this case reflects, the ease and extraordinary profits which can be generated from health care fraud is more than enough incentive for international organized crime syndicates to move into this area. With the uncovering of this scheme, we should fully expect that DOJ, HHS-OIG and other law enforcement agencies will continue to investigate these relationships.
Liles Parker attorneys represent health care providers around the country in administrative, civil and criminal health law related matters and cases. Please call us at 1 (800) 475-1906 for a free consultation.
South Texas Home Health Nurse Convicted of Health Care Fraud
(October 9, 2010): The U.S. Attorney’s Office for the Southern District of Texas recently issued a Press Release announcing the conviction of a South Texas nurse who worked for a Home Health company.
She allegedly admitted falsifying and forging encounter forms used when providing care for Medicare beneficiaries. More specifically, the nurse reportedly falsified information such as:
“. . .areas dealing with the beneficiary’s blood pressure, pulse rate, temperature, cardiac and respiratory status, homebound status and the medical supplies purportedly used during the visit.”
As the government’s release further notes, the nurse also allegedly admitted to forging beneficiary signatures on the bottom of the forms. Sentencing is scheduled for next January. She reportedly faces up to five years in Federal prison and a criminal fine of up to $250,000.
Commentary: While few facts regarding how this conduct was uncovered have been disclosed by the government, Home Health companies in the Valley should take note of the fact that Medicare providers in South Texas (especially Home Health companies, DME suppliers and Hospices) remain under considerable scrutiny by ZPICs, HHS-OIG, the State MFCU, the FBI and DOJ.
Under Health Care Reform’s mandatory compliance provisions, an effective Compliance Plan will soon be required of all providers. While many Home Health companies already have Compliance Plans in place, the question to be asked is simple: Would instances of improper billing, such as those outlined above, be disclosed as part of your normal Compliance Plan audit and review process? If not, you have a problem.
We recommend that you review your current compliance policies and procedures to better ensure that problems can readily be identified and fixed. Having said that, take care when engaging consultants to review your agency or practice. To the extent that serious problems are identified, the information learned may not be privileged. As a result, should the government investigate your company, you may be forced to disclose negative reports and other findings that your consultants have issued — essentially turning these internal audit documents into a “roadmap” for the prosecution. A better course is for you to work through your attorney. Have your attorney directly engage the consultant and supervise the review. That way, the report will be issued to your legal counsel. You may then at least arguably assert that any reports are privileged.
Liles Parker attorneys represent Home Health companies and other Medicare providers in South Texas. Our staff has extensive experience responding to ZPIC audits and other health care fraud investigations. Call us at 1 (800) 475-1906 for a free consultation.
Additional Cities will have HEAT Teams in 2011
(August 27, 2010): Yesterday, Attorney General Eric Holder and U. S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius conducted the second of a planned series of “Regional Health Care Fraud Prevention Summits.”
In addition to these agency heads, participants learned of current and additional planned initiatives from a number of Federal and State law enforcement officials. The first summit was recently conducted in Miami, Florida. This summit was held in Los Angeles, California.
Describing the progress made in the last fiscal year, Attorney General Holder noted that:
“In just the last fiscal year, we’ve won or negotiated more than $1.6 billion in judgments and settlements, returned more than $2.5 billion to the Medicare Trust Fund, opened thousands of new criminal and civil health care fraud investigations, reached an all-time high in the number of health care fraud defendants charged, and stopped numerous large-scale fraud schemes in their tracks.”
Notably, Attorney General Holder also made it clear that the government’s joint Health Care Fraud Prevention and Enforcement Action Team (HEAT) program is slated for further expansion over the next year. As he noted:
“HEAT’s impact has been recognized by President Obama, whose FY 2011 budget request includes an additional $60 million to expand our network of Strike Forces to additional cities. With these new resources, and our continued commitment to collaboration, I have no doubt we’ll be able to extend HEAT’s record of achievement. And this record is extraordinary. (emphasis added).
These funds will be to supplement, not supplant, existing health care fraud enforcement efforts currently underway. While the additional cities slated for HEAT expansion were not announced at this event, all health care providers, regardless of location, should be especially vigilant in their efforts to ensure that Medicare coding and billing practices regulating the items and services they are providing must comply with applicable statutory and agency requirements.
Should you have questions regarding a health care fraud issue, you may call Robert W. Liles or another of our attorneys. Call 1 (800) 475-1906 for a free consultation.
Medicare Fraud Strike Force Operation Leads to Charges against 94 Defendants, including 4 in South Texas
(July 17, 2010): Yesterday, the Department of Justice (DOJ) announced charges against 94 physicians, medical assistants, and health care company owners and executives in connection with alleged false Medicare claims amounting to more than $251 million. 24 defendants from Miami account for approximately $103 million of that amount. Four defendants were charged in Houston for their alleged roles in a $3 million scheme to submit fraudulent claims for durable medical equipment (DME). Other arrests were made in Baton Rouge, Brooklyn, and Detroit.
The offenses charged include conspiracy to defraud the Medicare program, criminal false claims, violations of the anti-kickback statutes, and money laundering. The charges are based on a variety of fraud schemes, including physical therapy and occupational therapy schemes, home health care schemes, HIV infusion fraud schemes and durable medical equipment (DME) schemes.
Announcing the arrests, Attorney General Eric Holder said, “With today’s arrests, we’re putting would-be criminals on notice: Health care fraud is no longer a safe bet. It’s no longer easy money. If you choose to engage in health care fraud, you will be found; you will be stopped; and you will be brought to justice.”
The operation was conducted by the joint DOJ-HHS Medicare Fraud Strike Force, multi-agency teams of federal, state, and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Strike Force teams are operating in seven cities in the United States: the five aforementioned cities, Los Angeles, and Tampa. AG Holder noted that the ongoing Strike Force initiative in South Florida has resulted in the indictments of 810 organizations and individuals since March 2007 and uncovered $1.85 billion in improperly billed claims.
The Strike Forces are a part of Health Care Fraud Prevention and Enforcement Action Team (HEAT), which is made up of top level law enforcement and professional staff from the DOJ and HHS and their operating divisions. HEAT is dedicated to joint efforts across government to both prevent fraud and enforce current anti-fraud laws around the country.
Should you have any questions regarding these issues, don’t hesitate to contact us. For a complementary consultation, you may call Robert W. Liles or one of our other attorneys at 1 (800) 475-1906.
Texas Physician Indicted and Arrested
(July 9, 2010): On June 14, 2010 the U.S. Attorney’s Office for the Western District of Texas announced that a Federal Grand Jury had returned a 99-count indictment against a pain management physician who operated clinics in San Antonio and El Paso. The physician was charged with 21 counts of health care fraud, 20 counts of false statements relating to health care fraud matters, 21 counts of mail fraud, 16 counts of wire fraud, 4 counts of unlawful distribution of a controlled substances and 16 counts of money laundering. The indictment alleges that the physician “caused to be submitted claims for reimbursement of peripheral nerve injections, facet injection procedures and Level Four office visits–typically involving 25 minutes of face-to-face time between patient and physician–which never were performed.” Instead, the U.S. Attorney’s Office alleges that the physician performed “prolotherapy” on his patients — a procedure that Federal health care benefit programs do not reimburse.
Notably, an indictment is merely a charge and is not considered to be evidence of guilt. In issuing this indictment, the Texas HEAT task force, comprised of Federal prosecutors and investigative agencies, have continued to ramp up efforts to investigate and prosecute allegations of health care fraud. Notably, the use of “prolotherapy,” a relatively new therapeutic approach, has been supported by some of the best known clinics and physicians in the country.
While this case has yet to fully develop, it again points out that health care providers must take care when utilizing new approaches, despite the fact the therapeutic technique may be considered to be state-of-the-art. Unfortunately, Medicare may take years to recognize and cover some techniques. In the mean time, it is essential that providers take care when coding and billing for procedures that may not clearly qualify for coverage under applicable Medicare and / or contractor guidance.
Should you have any questions regarding these issues, don’t hesitate to contact us. For a complementary consultation, you may call Robert W. Liles or one of our other attorneys at 1 (800) 475-1906.
HEAT Enforcement Update: Investigations and Prosecutions in Texas Increased in March 2010
(April 3, 2010): Notably, the number of publicly-disclosed investigations and prosecutions in Texas significantly increased last month. Two of the cases disclosed involved mental health professionals.
- A Psychologist was convicted of health care fraud and money laundering, in connection with various claims fraudulently billed to Medicare. Instances of improper conduct included billing for more than twenty-four hours of services in a single day; billing for services in a single day which amounted to more than double the normal business hours of the Psychologist’s practice; billing for services allegedly rendered during weekends, holidays, and times that the Psychologist was known to be out of town and away from the practice; and, submitting claims for services and evaluations not actually performed by the Psychologist, as required by law.
- An unlicensed Behavioral Health Counselor was charged with Medicaid fraud for allegedly engaging in aggravated identity theft. The defendant allegedly improperly acquired Medicaid beneficiaries’ information, including names, addresses and Medicaid numbers, then used the information to file false claims through a behavioral counseling service the defendant owned. These behavioral counseling services were billed to Medicaid but allegedly not provided to the beneficiaries for which they were billed.
Since being established approximately a year, Texas HEAT team investigations and prosecutions have significantly increased throughout the State. Both enforcement efforts and the frequency of Medicare audits are anticipated to increase throughout 2010. In addition to the increasing number of civil and criminal cases brought by the Texas HEAT Strike Forces, the number of administrative overpayment cases is anticipated to grow as well. It is essential that CMHCs continue in their efforts to ensure that both business operations and billing practices fully comply with applicable statutory and regulatory requirements.
Our Firm includes a number of attorneys with extensive former experience as Federal and / or State prosecutors. Should your organization find itself under investigation, you may give us a call for a complementary consultation at: 1 (800) 475-1906.
