Original story posted on: March 9, 2012

Ongoing Fraud Investigation in Chicago Nets 2 Doctors, 4 Nurses

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Updated on: January 31, 2013

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Eleven more people have been charged in an alleged fraud scheme involving two Chicago-area home health agencies.

The original defendant, Jacinto "John" Gabriel Jr., operated the now-defunct home health agencies, one that billed Medicare $38 million between 2006 and 2011 and one that billed $6 million between 2008 and 2011, according to the U.S. Attorney's Office in northern Illinois.

Gabriel and three other defendants authorized payment of $200 to $800 to people including a physician for each patient they referred to home health, according to the U.S. Attorney's Office in northern Illinois.

Gabriel also directed employees to list false diagnoses, including joint disease and hypertension, to bill for higher reimbursement, the U.S. Attorney's Office stated.

Other charges for the defendants include failing to pay taxes and filing false tax returns, the U.S. Attorney's Office stated.

Also in recent fraud news:

  • Beth Israel Medical Center has settled a false claims lawsuit for $13 million, according to the U.S. Attorney's Office in southern New York. The hospital inflated its fees to obtain outlier payments though the services did not qualify for those payments, the U.S. Attorney's Office stated.
  • Nine people including five doctors were charged in a scheme that allegedly involved kickbacks for referrals for electrodiagnostic testing, physical therapy and home health services, according to U.S. Attorney's Office in western Michigan. Other kickbacks were disguised as mileage payments, medical director fees, continuing medical education and contractual labor, the U.S. Attorney's Office stated.

Region A: Watch for ADR Changes

In recovery auditor news, the Region A RAC DCS Healthcare will send one additional documentation request (ADR) letter that combines all issues into one letter, the RAC stated on its website. Previously, the RAC sent letters for each issue.

The size of the envelope could vary also depending on the number of pages in the letter, but the envelopes will be white with the blue DCS Healthcare logo, the RAC stated.

Other changes in the letter include an improved description of how to format and send medical documentation and references to the esMD program to submit documentation, the RAC stated.

For a template of the new letter, visit http://www.dcsrac.com/Portals/0/ADR%20New%20Letter%20Template%20-%20Final.pdf.

RACs Post Physician, Hospital Issues

Connolly, the Region C RAC posted two issues for physicians - one about visits to patients in nursing facilities and one about an incorrect fee schedule applied to carrier claims.

Connolly also posted one inpatient hospital issue along with five inpatient hospital issues posted by HealthDataInsights, the Region D RAC.

For more about the issues, see the chart below.


 

Physicians

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Visits to patients in nursing facilities

3/5/12

RAC Region C

If evaluation and management services are being rendered to patients in a skilled nursing facility, then the appropriate E&M codes are to be used.

CMS Pub. 100-04 chapter 12

Incorrect fee schedule applied to carrier claims

3/5/12

RAC Region C

Overpayments identified on carrier claims that were reimbursed in accordance with the wrong fee schedule.

RAC statement of work 9/1/11; CMS physician fee schedule search; MLN Matters articles MM6351, MM6397, MM6484, MM6617, MM7112, MM6974, MM6973, MM6796, MM7528, MM7430, MM5980, MM6087, MM6180; CMS Pub. 100-04 chapters 12, 26; CMS Transmittal 2353/change request 7634

 

Inpatient hospitals

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - major chest procedures (DRGs 163, 164, 165, 166, 167, 228, 229, 230)

3/6/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

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

Acute inpatient hospitalization - multiple significant trauma (DRGs 955, 956, 957, 958, 959, 965)

3/6/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

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

Acute inpatient hospitalization - procedures for obesity (DRGs 619, 620, 621)

3/5/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

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

Acute inpatient hospitalization - myeloproliferative disorders (DRGs 802, 803, 826, 827, 828, 829, 830, 837, 843)

3/5/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

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


Inpatient hospitals (CONT'D)

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute inpatient hospitalization - nonbacterial infections (DRGs 969, 970, 974, 975)

3/5/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

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

Late submissions of IRF-PAI data

3/5/12

RAC Region C

Inpatient rehabilitation facility patient assessment instrument (IRF-PAI) data, which is collected on Medicare Part A fee-for-service inpatients, must be transmitted to the CMS National Assessment Collection Database by the 17th calendar day from the date of the patient's discharge. Transmission of the IRF-PAI data record 28 or more calendar days after the discharge date, with the discharge date itself starting the counting sequence, will result in the claim incurring a 25 percent late-transmission penalty.

OIG report A-01-09-00507; CMS Pub. 100-04 chapter 3

 

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

To comment on this article please go to editor@racmonitor.com

Reporting and Returning Overpayments

Karen Long

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