DME Fraud Sentence Heaped on top of Home Health Fraud Sentence for Houston Pair

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Original story posted on: July 30, 2012

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A judge piled on 87-month prison sentences for durable medical equipment (DME) fraud for a Houston pair that already had been sentenced to 108 months in prison for a $5.2 million home health scheme.

The former owners of Family Healthcare Services, Clifford Ubani and Princewill Njoku, would file Medicare claims for DME that was not provided or medically necessary, according to the Justice Department. The equipment was marketed as “arthritis kits” or “ortho kids” that were unnecessary orthotic braces. 

Each pleaded guilty to one count of conspiracy to commit health care fraud in 2010, the Justice Department stated.

Their sentences will be served concurrently. They and their codefendants also have to pay more than $566,000 in restitution.

In other fraud news:

  • Madison, Wis., woman pleads guilty to one count of making false statements about using federal funds.

Sunshine House, an organization for which Amy Kuhner was the executive director, received an $836,190 federal grant to construct a facility for seriously ill children, the Federal Bureau of Investigation (FBI) stated. Kuhner falsified documents about costs that occurred during the grant period and instead received a gross salary of almost $418,000 plus more than $22,000 in benefits, mostly paid using the grant money. She faces up to five years in prison and a $250,000 fine.

  • Paying kickbacks to beneficiaries and patient recruiters nets 60 months in prison for Miami-area man.

Emilio Haber allegedly paid recruiters $100 to $150 per patient sent to two Michigan clinics and $50 to $75 for the patient to undergo medically unnecessary tests, the Justice Department stated. He and co-conspirators told patients to feign symptoms to justify tests such as nerve conduction studies. The scheme resulted in $8.5 million in fraudulent claims submitted to Medicare from August 2007 to October 2009. Along with the prison sentence, Haber must pay more than $6.3 in restitution and forfeit $99,000 seized from his bank accounts.

  • Rhode Island physician assistant sentenced to six months in prison, six months of home confinement for anti-kickback violations.

Michael Cobb took kickbacks from Orthofix Inc., a medical device company, in return for ordering the company’s devices, according to the U.S. Attorney in Massachusetts. For each bone growth stimulator the doctor ordered, Cobb received $50 to $300, totaling $120,000 from 2004 to 2011. Orthofix has agreed to pay $42 million in relation to illegal promotion of the stimulators, and other executive and employees also have pleaded guilty to related charges.

2 RACs Post Issues

Recovery auditors in regions A and C posted issues this week for DME suppliers, home health agencies and inpatient hospitals. For more details, check out the charts below.

DME supplier

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Complex enteral nutrition infusion pumps

7/25/12

RAC Region A

Enteral nutrition infusion pump claims that do not meet the indications of coverage or medical necessity related to LCD L5041 (A25229).

CMS Pub. 100-02 chapter 15; CMS Pub. 100-08 chapter 5; CMS Pub. 100-04 chapters 20, 30; CMS Pub. 100-03 chapter 1; NHIC Medicare Services LCD L5041; OIG reports OEI-03-02-00700, OEI-06-07-00090; DME coding system, DME pricing data anlaysis coding, eteral nutrition

 


 

Home health agency

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity and conditions to qualify for services

6/29/12

RAC Region C

Medical record will be reviewed to validate that the home health services provided were both reasonable and medically necessary and that the patient met the conditions to qualify for home health services.

CMS Pub. 100-02 chapter 7

 

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Long-term care hospital patients not meeting medical necessity criteria

6/29/12

RAC Region C

Medicare pays for inpatient hospital services that are medically reasonable and necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically reasonable and necessary. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for hospital-level medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.

CMS Pub. 100-08 chapter 6; CMS Pub. 100-02 chapter 1

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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